Adriana C. Lunardi

Incentive spirometry in major surgeries: a systematic review

OBJECTIVE To conduct a systematic review to evaluate the evidence of the use of incentive spirometry (IS) for the prevention of postoperative pulmonary complications and for the recovery of pulmonary function in patients undergoing abdominal, cardiac and thoracic surgeries. METHODS Searches were performed in the following databases: Medline, Embase, Web of Science, PEDro and Scopus to select randomized controlled trials which the IS was used in pre- and/or post-operative in order to prevent postoperative pulmonary complications and/or recover lung function after abdominal, cardiac and thoracic surgery. Two reviewers independently assessed all studies. In addition, the studies quality was assessed using the PEDro scale. RESULTS Thirty studies were included (14 abdominal, 13 cardiac and 3 thoracic surgery; n=3,370 patients). In the analysis of the methodological quality, studies achieved a PEDro average score of 5.6, 4.7 and 4.8 points in abdominal, cardiac and thoracic surgeries, respectively. Five studies (3 abdominal, 1 cardiac and 1 thoracic surgery) compared the effect of the IS with control group (no intervention) and no difference was detected in the evaluated outcomes. CONCLUSION There was no evidence to support the use of incentive spirometry in the management of surgical patients. Despite this, the use of incentive spirometry remains widely used without standardization in clinical practice.

Musculoskeletal dysfunction and pain in adults with asthma.

Background. The mechanical alterations related to the overload of respiratory muscles observed in adults with persistent asthma might lead to the development of chronic alterations in posture, musculoskeletal dysfunction and pain; however, these changes remain poorly understood. Objective. This study aimed to assess postural alignment, muscle shortening and chronic pain in adults with persistent asthma. Methods. This cross-sectional and controlled study enrolled 30 patients with mild (n = 17) and severe (n = 13) persistent asthma. Fifteen non-asthmatic volunteers were also assessed. Asthma was classified by the Global Initiative for Asthma (GINA) guidelines. Postural alignment and muscle shortening were evaluated by head and shoulder positions, chest wall mobility, and posterior (trunk and lower limb) muscle flexibility. In addition, the measures used were previously tested for their reproducibility. Pain complaints were also assessed. Results. In comparison with non-asthmatic subjects, patients with mild or severe persistent asthma held their head and shoulders more forward and had lower chest wall expansion, decreased shoulder internal rotation, and decreased thoracic spine flexibility. Chronic lower thoracic, cervical, and shoulder pain was significantly increased in patients with mild or severe asthma compared with non-asthmatic subjects (p < 0.05). Conclusion. Adults with persistent asthma have musculoskeletal dysfunction and chronic pain that is independent of the severity of their disease but that might be related to their age at the onset of disease symptoms.

Effect of Volume-Oriented Versus Flow-Oriented Incentive Spirometry on Chest Wall Volumes, Inspiratory Muscle Activity, and Thoracoabdominal Synchrony in the Elderly

BACKGROUND: Aging causes physiological and functional changes that impair pulmonary function. Incentive spirometry is widely used for lung expansion, but the effects of volume-oriented incentive spirometry (VIS) versus flow-oriented incentive spirometry (FIS) on chest wall volumes, inspiratory muscle activity, and thoracoabdominal synchrony in the elderly are poorly understood. We compared VIS and FIS in elderly subjects and healthy adult subjects. METHODS: Sixteen elderly subjects (9 women, mean ± SD age 70.6 ± 3.9 y, mean ± SD body mass index 23.8 ± 2.5 kg/m2) and 16 healthy adults (8 women, mean ± age 25.9 ± 4.3 y, mean ± body mass index 23.6 ± 2.4 kg/m2) performed quiet breathing, VIS, and FIS in randomized sequence. Chest wall kinematics (via optoelectronic plethysmography) and inspiratory muscle activity (via surface electromyography) were assessed simultaneously. Synchrony between the superior thorax and abdominal motion was calculated (phase angle). RESULTS: In the elderly subjects both types of incentive spirometry increased chest wall volumes similarly, whereas in the healthy adult subjects VIS increased the chest wall volume more than did FIS. FIS and VIS triggered similar lower thoracoabdominal synchrony in the elderly subjects, whereas in the healthy adults FIS induced lower synchrony than did VIS. FIS required more muscle activity in the elderly subjects to create an increase in chest wall volume. CONCLUSIONS: Incentive spirometry performance is influenced by age, and the differences between elderly and healthy adults response should be considered in clinical practice.

Postoperative chest physical therapy prevents respiratory complications in patients undergoing esophagectomy

BACKGROUND Esophagectomy presents the highest rate of postoperative pulmonary complications among all types of upper abdominal surgery. The benefits of chest physical therapy in patients undergoing upper abdominal surgery have been shown by many studies; however, its specific effect in patients receiving esophagectomy has been seldom investigated. OBJECTIVES This study aimed to compare the frequency of respiratory complications in patients undergoing esophagectomy receiving chest physical therapy compared to no treatment. METHODS 70 consecutive patients were evaluated retrospectively and allocated to two groups: control group (CG=no physical therapy; n=30) and chest physical therapy group (PTG; n=40). Patients received chest physical therapy which includes lung re-expansion and airway clearance maneuvers. They were not submitted to either noninvasive ventilation or exercises with devices that generate airways positive pressure. All patients were instructed to early mobilization. Information about pre-operative and respiratory complications were collected. Statistic analysis to compare the frequency of respiratory complications was performed by the Z test. The significance level was set to 5%. RESULTS Patients in the CG and PTG were similar in terms of age, BMI, smoking and drinking status, malignant diseases, surgical and anesthesia duration and types of esophagectomy (p>0.05). Our results show that patients received chest physical therapy after esophagectomy had a lower frequency of respiratory complications (15% vs. 37%, p<0.05). In addition, the PTG needed a shorter duration of antibiotic treatment and thoracic drainage as well as less re-intubation compared with the control group (p<0.05). CONCLUSIONS Our results suggest that chest physical therapy treatment reduces respiratory complications and the need for care but does not influence on hospital length of stay.CONTEXTUALIZACAO: A esofagectomia apresenta a maior taxa de complicacoes pulmonares pos-operatorias dentre as cirurgias abdominais altas. Os beneficios da fisioterapia respiratoria em pacientes submetidos a cirurgia abdominal alta convencional tem sido mostrados na literatura, porem esse efeito na esofagectomia tem sido pouco investigado. OBJETIVOS: Comparar a frequencia de complicacoes respiratorias em dois grupos de pacientes submetidos a esofagectomia, tendo um recebido fisioterapia respiratoria e o outro nao. METODOS: Setenta pacientes consecutivos (nenhuma exclusao) foram avaliados retrospectivamente e divididos em dois grupos: controle (GC=sem fisioterapia; n=30) e fisioterapia respiratoria (GFT; n=40). O PTG recebeu manobras para expansao pulmonar e higiene das vias aereas. Nenhum deles foi submetido a ventilacao nao-invasiva ou a exercicios com pressao positiva. Todos os pacientes foram orientados a mobilizacao ativa, progressiva e precoce. Foram coletadas informacoes sobre o perioperatorio e complicacoes respiratorias. A frequencia de complicacoes respiratorias entre os grupos foi analisada pelo teste z, considerando p 0,05). Nossos resultados mostram que pacientes que receberam fisioterapia respiratoria apos a esofagectomia tiveram uma frequencia menor de complicacoes respiratorias (15% vs. 37%, p<0,05). O PTG precisou de menos tempo de antibioticoterapia e de drenagem toracica, assim como teve menos reintubacao, comparado com o controle (p<0,05). CONCLUSOES: Os resultados sugerem que a fisioterapia respiratoria apos esofagectomia reduz as complicacoes respiratorias e a necessidade de cuidados clinicos, mas nao reduz o tempo de hospitalizacao.

Preoperative six-min walking distance does not predict pulmonary complications in upper abdominal surgery

Background and objective:  Field exercise tests have been increasingly used for pulmonary risk assessment. The six‐min walking distance (6MWD) is a field test commonly employed in clinical practice; however, there is limited evidence supporting its use as a risk assessment method in abdominal surgery. The aim was to assess if the 6MWD can predict the development of post‐operative pulmonary complications (PPCs) in patients having upper abdominal surgery (UAS).

Volume Rather Than Flow Incentive Spirometry Is Effective in Improving Chest Wall Expansion and Abdominal Displacement Using Optoelectronic Plethysmography

BACKGROUND: Incentive spirometers are widely used in clinical practice and classified as flow-oriented (FIS) and volume-oriented (VIS). Until recently the respiratory inductive plethysmography used to evaluate the effects of incentive spirometry on chest wall mechanics presented limitations, which may explain why the impact of VIS and FIS remains poorly known. OBJECTIVE: To compare the effects of VIS and FIS on thoracoabdominal mechanics and respiratory muscle activity in healthy volunteers. METHODS: This cross-sectional trial assessed 20 subjects (12 female, ages 20–40 years, body mass index 20–30 kg/m2). All subjects performed 8 quiet breaths and 8 deep breaths with FIS and VIS, in a randomized order. We measured thoracoabdominal chest wall, upper and lower rib-cage, and abdominal volumes with optoelectronic plethysmography, and the muscle activity of the sternocleidomastoid and superior and inferior intercostal muscles with electromyography. RESULTS: VIS increased chest wall volume more than did FIS (P = .007) and induced a larger increase in the upper and lower rib-cages and abdomen (156%, 91%, and 151%, respectively, P < .001). By contrast, FIS induced more activity in the accessory muscles of respiration than did VIS (P < .001). CONCLUSIONS: VIS promotes a greater increase in chest wall volume, with a larger abdominal contribution and lower respiratory muscle activity, than does FIS in healthy adults.

Anxiety and depression are related to dyspnea and clinical control but not with thoracoabdominal mechanics in patients with COPD.

OBJECTIVE To investigate the relationship between the presence of symptoms of anxiety or depression with breathing pattern and thoracoabdominal mechanics at rest and during exercise in COPD. METHODS Cross-sectional study enrolled 54 patients with COPD ranked according to Hospital Anxiety and Depression Scale (HAD) score and compared to dyspnea, clinical control, hypercapnia, breathing pattern and thoracoabdominal mechanics at rest and during exercise. RESULTS Seventeen patients with COPD had no symptoms, 12 had anxiety symptoms, 13 had depressive symptoms and 12 had both symptoms. COPD with depressive symptoms presented greater degree of dyspnea (p<0.01). Poor clinical control was observed in COPD with anxious and/or depressive symptoms (p<0.05). Breathing pattern and thoracoabdominal mechanics were similar among all groups at rest and during exercise. CONCLUSIONS COPD with symptoms of depression report more dyspnea. Anxiety and depression are associated with poor clinical control without impact on breathing pattern and thoracoabdominal mechanics in COPD.

Comparison of Lung Expansion Techniques on Thoracoabdominal Mechanics and Incidence of Pulmonary Complications After Upper Abdominal Surgery: A Randomized and Controlled Trial

OBJECTIVE Lung expansion techniques (LETs) are widely used to prevent postoperative pulmonary complications (PPCs). However, the effects of each of these techniques on thoracoabdominal mechanics and PPC incidence after abdominal surgery remain unclear. The objective of this study was to compare the effects of LET on pulmonary volumes, respiratory muscle activation, and PPC incidence after major, elective upper abdominal surgery. METHODS This randomized controlled trial enrolled 137 patients who were randomly assigned into four groups: control (n = 35), flow incentive spirometry (n = 33), deep breathing (n = 35), and volume incentive spirometry (n = 34). Each intervention was performed tid during 5 consecutive days. Subsequently, PPCs (pneumonia, atelectasis, or severe hypoxemia) were analyzed by a blinded assessor until hospital discharge. Lung volumes (optoelectronic plethysmography) and inspiratory muscular activation (surface electromyography) were assessed before and 3 days after surgery. Intention-to-treat analysis was performed. RESULTS Before surgery, all groups were homogenous for age, sex, BMI, lung function, and thoracoabdominal mechanics. After surgery, no difference was observed in the lung volumes and inspiratory muscular activation during the lung expansion technique (P > .05). The PPC incidence was higher in the deep breathing group (P < .05). Higher American Society of Anesthesiologists scores and surgery duration were the only predictors of PPC (n = 14, 11.2%). CONCLUSIONS LETs do not modify the changes on thoracoabdominal mechanics or prevent PPCs after abdominal surgery. The indiscriminate use of LETs should not be routinely prescribed to prevent PPCs; however, more studies are required to confirm our results and to change the standard practice. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01993602; URL: www.clinicaltrials.gov.

Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review

Background Falls are a geriatric syndrome that is considered a significant public health problem in terms of morbidity and mortality because they lead to a decline in functional capacity and an impaired quality of life in the elderly. Lower limb muscle strengthening seems to be an effective intervention for preventing falls; however, there is no consensus regarding the best method for increasing lower limb muscle strength. Objectives To analyze the effectiveness of lower limb muscle strengthening and to investigate and describe the protocols used for preventing falls in elderly subjects. Method We performed a systematic review of randomized and controlled clinical trials published between 2002 and 2012 in the databases PubMed, EMBASE, Scopus, Web of Science, and PEDro that cited some type of lower limb muscle strengthening protocol and that evaluated the incidence of falls as the primary outcome exclusively in elderly subjects. Twelve studies met the inclusion criteria. Qualitative analysis was performed by independent reviewers applying the PEDro scale. Results The data obtained from the selected studies showed lower fall rates in the intervention groups compared to controls. Six studies described the lower limb muscle strengthening protocol in detail. High methodological quality was found in 6 studies (PEDro score ≥7/10 points). Conclusions The methodological quality of the studies in this area appears to leave little doubt regarding the effectiveness of lower limb strengthening exercises for preventing falls in elderly subjects, however the interventions in these studies were poorly reported.

Association between Maximal Aerobic Capacity and Psychosocial Factors in Adults With Moderate-to-Severe Asthma

Background. The symptoms of asthma impair health-related quality of life (HRQoL), increase anxiety and depression and may keep subjects from engaging in physical exercise. Physical inactivity has been related to poor asthma outcomes; however, the association between physical fitness and psychosocial disorders remains poorly understood. Objective. To verify the association between aerobic capacity, HRQoL, and psychological distress in adults with moderate or severe persistent asthma who were clinically stable. Methods. Eighty-eight participants (68 females) with either moderate or severe persistent asthma (age range, 20–60 years) who were under medical treatment for at least 6 months and considered clinically stable were studied. Participants were evaluated on two non-consecutive days. On the first day, the HRQoL, depression and anxiety levels and pulmonary function were assessed. On the second day, subjects underwent cardiopulmonary exercise testing. Results. Using the agglomerative cluster approach, two clusters were identified: 21 participants (24%) were grouped in Cluster 1, and 67 (76%) were grouped in Cluster 2. Asthmatic subjects from Cluster 1 exhibited increased aerobic capacity, better HRQoL and lower depression levels than did subjects in Cluster 2 (p < .05). No difference was observed between the clusters with respect to gender, age, body mass index (BMI) or pulmonary function (p > .05). The discriminant function model exhibits good accuracy (R2 = 0.79) and predicted 93% of the case allocations. Conclusion. Our results suggest an association between reduced exercise capacity, low HRQoL and increases in depressive symptoms in clinically stable asthmatic subjects. These results suggest the need to assess physical fitness and psychosocial distress during asthma treatment and the importance of a multidisciplinary approach.