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Clinical Question After coronary artery bypass surgery, does deep breathing reduce atelectasis and improve pulmonary function? Citation Deep-Breathing Exercises Reduce Atelectasis and Improve Pulmonary Function After Coronary Artery Bypass Surgery* Study Characteristics 1. Patients included (Population and Sample) A sample of 115 patients undergoing CABG surgery at a university hospital were invited to participate in the study. 2. Interventions compared All data were collected and analyzed in a statistical computer program (StatView; Abacus Concepts; Berkeley, CA) and presented as mean values SD. Baseline data were compared by unpaired t test or by 2 test. The relative decrease in pulmonary function after the operation, the atelectatic area, and arterial blood gases were compared by an unpaired t test. Including 45 patients per group would yield 80% power ( = 0.05) to detect a decrease from 2.5 to 1.9% (percentage reduction, 20 to 25%) in bilateral atelectatic area in percentage of total lung area between groups, assuming a SD of 1.0%. This difference is assumed by the authors to be of clinical relevance. Dropout was anticipated to be up to 20%, and hence another 10 patients were included in each group. All results refer to twosided tests, and p < 0.05 was considered significant. 3. Outcomes monitored The patients were encouraged to perform the deep-breathing exercises once per hour throughout the day. The frequency (three sets of 10 breaths) was chosen according to the ordinary routines at the clinic. Compliance with the suggested exercises was not objectively measured, but it was self-reported by the patients in the deep-breathing group. The reported number of exercise sessions performed each day might be considered acceptable and is in accordance with what one can achieve in a clinical situation. At present, it is not known if increasing the frequency and intensity of the exercises is likely to be more efficacious. All patients found the breathing technique easy to perform, and most of the patients experienced a subjective benefit of the exercises; this is important for completion of the treatment. In our study, pulmonary function measurement was performed preoperatively and repeated on the fourth postoperative day. A marked reduction in lung volumes was present on the fourth postoperative day, which was of the same extent as found in previous investigations after CABG surgery. A slightly better preservation of spirometric variables was also seen in the deep-breathing group compared to the control group on the fourth postoperative day; however, the effect on atelectasis was more obvious than the spirometric results. However, a correlation was found between atelectasis and worsening in FEV1, similar to a previous study15 on postoperative atelectasis after abdominal surgery. CT can give reliable measurement of atelectasis, but it is worth noting that up to this time CT has not been used in the evaluation of prophylactic chest physical therapy following cardiac surgery. Clear effects of deep breathing on pulmonary function parameters after cardiac surgery have earlier not been documented, and this could possibly be explained by the choice of outcome measures. Studies including control group patients who did not receive chest physiotherapy at all have been limited, and none of these studies have shown benefits from treatment regimens. Even though our patients were seen by a physical therapist daily and were instructed in active exercises and

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mobilized early, the patients in the deep-breathing group still had better pulmonary function and smaller atelectatic areas. A weak correlation between atelectatic areas and Pao2 has earlier been presented, but in the present study no significant difference in oxygenation was apparent between the deep-breathing group and the control group. Recruited lung tissue is most likely converted from a shunt region to a zone with low ventilation in relation to perfusion, still contributing to poor oxygenation of blood. Arterial oxygenation is also influenced by nonpulmonary factors such as mixed venous oxygen tension or cardiac output and efficiency of hypoxic pulmonary vasoconstriction.23 It should also be emphasized that atelectasis is a locus for inflammation. A variety of signs and symptoms can identify a postoperative pulmonary complication. The presence of atelectasis in combination with other chosen factors is often a criterion for the definition. Whether a reduced amount of atelectasis can decrease postoperative lung complications, if atelectasis is not considered a complication, remains to be tested. 4. Does the study focus on a significant problem in clinical practice? Yes, the study focused on a significant problem in clinical practice since the intervention was clearly applied to the participants.

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Methodology / Design 1. Methodology used All patients received general anesthesia, and the CABG was performed with saphenous veins and in most cases the left internal mammary artery. During anesthesia and following surgery, all patients inspired oxygen with a concentration of 40 to 80%. The surgical approach was through a median sternotomy. Cold-blood cardioplegia and occasionally topical cooling of the heart were used. An insulation pad was used to protect the phrenic nerve. The pericardium, the mediastinum and, occasionally one or both pleura were drained, usually < 24 h after surgery. 2. Design Prospective and randomized trial was the design used for this study. 3. Setting In a prospective, randomized trial, patients performing deep-breathing exercises (n = 48) were compared to a control group (n = 42) who performed no breathing exercises postoperatively. Patient management was similar in the groups in terms of assessment, positioning, and mobility. 4. Data sources Crowe, JM, Bradley, CA (1997) The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther 77,260-268; Johnson, D, Kelm, C, To, T, et al Postoperative physical therapy after coronary artery bypass surgery. Am J Respir Crit Care Med 1995;152,953-958; Jenkins, SC, Soutar, SA, Loukota, JM, et al Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax 1989;44,634-639; Stiller, K, Montarello, J, Wallace, M, et al Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery. Chest 1994;105,741-747; Brasher, PA, McClelland, KH, Denehy, L, et al Does removal of deep breathing exercises from a physiotherapy program including pre-operative education and early mobilisation after cardiac surgery alter patient outcomes? Aust J Physiother 2003;49,165-173

5. Subject selection a. Inclusion criteria The patients were randomized to a deep-breathing group (n = 57) that performed deep-breathing exercises postoperatively and to a control group (n = 55) that performed no breathing exercises. Informed consent was obtained from each patient, and the study was approved by the local research ethics committee. b. Exclusion criteria Patients who had an emergency operation, previous cardiac surgery, severe renal dysfunction, or difficulties in cooperating during measurements were not included. Three patients declined participation. 6. Has the original study been replicated? This study is an original study and has not been replicated yet. 7. What were the risks and benefits of the nursing action/intervention tested in the study? There were no risks in this study for applying the interventions would not make further harm to the patients. This study in fact produced a positive outcome for all patients found the breathing technique easy to perform, and most of the patients experienced a subjective benefit of the exercises, which is important for completion of the treatment. V. Results of the study Five women and 17 men (mean age SD, 68 11 years) were excluded for various reasons. In total, 90 patients (23 women and 67 men) were investigated. Demographic and surgical data did not significantly differ between the two groups. Pain from the sternotomy did not differ between the two groups. Mean value for the visual analog scale at rest was 1.4 1.6 cm; while taking a deep breath, 2.5 2.1 cm; while coughing, 4.3 2.8 cm; and during pulmonary function testing, 2.4 2.2 cm. No significant differences in length of ICU stay (deepbreathing group, 17.9 5.3 h; control group, 18.8 4.0 h), postoperative hospital stay (5.5 2.8 days vs 5.3 2.6 days), or fever (mean value for the 4 postoperative days, 37.5 0.3C vs 37.6 0.4C) were noticed. None of the patients had signs of pneumonia during the hospital stay. One of the excluded patients received antibiotics because of a sternal infection. Authors Conclusions / Recommendations 1. What contribution to client health status does the nursing action / intervention make? This studys objective was to investigate the effects of deep-breathing exercises on pulmonary function, atelectasis, and arterial blood gas levels after coronary artery bypass graft (CABG) surgery. In the deep-breathing group of this study, 72% of the patients experienced a subjective benefit from the exercises which I think is a big contribution to the client health status which may facilitate faster recovery of the patients. 2. What overall contribution to nursing knowledge does the study make? One contribution of this study in the nursing knowledge is that they were able to open new learning regarding breathing exercises. A new knowledge was open concerning better pulmonary functions with the use of deep breathing exercises. VII. Applicability 1. Does the study provide a direct enough answer to your clinical question in terms of type of patients, interventions and outcome? This study provides a direct enough answer to the clinical question since it really focused on the subject matter.

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Is it feasible to carry out the nursing action in the real world?

We think that it is feasible to be carried out in the real world for the reason that this study will produce no further harm to the patients. Instead, it will produce benefit as earlier stated by the participants of this study.

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Reviewers Conclusion / Commentary This study shows that performing deep-breathing exercises after CABG surgery had significantly smaller atelectatic areas and better pulmonary function on the fourth postoperative day compared to a control group performing no exercises. The results of this study will enable the institutions to facilitate better and faster recovery of patients who have undergone coronary artery bypass surgery. As a health care provider, we should be concern of our patients health status and we must expand our knowledge in order to help them achieve better healing. This study would be effective because of the beneficial effects reported by the patients by performing of deep breathing exercises which improve pulmonary functions.

Reference: Deep-Breathing Exercises Reduce Atelectasis and Improve Pulmonary Function After Coronary Artery Bypass Surgery* By Elisabeth Westerdahl, RPT, PhD, Birgitta Lindmark, RPT, PhD, Tomas Eriksson, MD, rjan Friberg, MD, Gran Hedenstierna, MD, PhD, FCCP, and Arne Tenling, MD, PhD. http://www.chestjournal.org/content/128/5/3482.full