Comparison of Two Methods of Postoperative Respiratory Care

Comparison of Two Methods of Postoperative Respiratory Care* Shufi Dohi, M.D., 0

0

and Martin I. Gold, M.D.t

After abdominal smpry, 64 patients were llUUlllpd with one of the following two teclmlques of respiratory care: (1) deep breathing by way of a new device,• incentive splrometric tbree-ball, ftow-wrhag device (frifto); •d (2) standard episodic Intermittent posltive-prelllll'e breathing (IPPB) every four hours. Both series of patients received therapy with a broncbodilator drag by nebulbation. All patients bad preoperative splrometric meaurements followed by ftve comecutlve days of 1berapy and splrometry. Chest ~-ray ftbm were obmlned for all patients. There were no lignUlcut differences between the two methods of respiratory care, bnt 57 percent (17I JO)

In the IP'OUP receiving therapy with IPPB developed pneumonia, atelecbllis, or bronchitis, while only 29 percent (10/34) clld so In the group using the incentive splrometric device (P < 0.05), Splrometric differences were minimal, although the trend favored the Incentive spirometric device, Principal conclusions were • follows: (1) deep breathing under the conditions of this Investigation was equal to episodic therapy with IPPB; and (2) from an economic standpoint, IPPB, • It Is currently practiced, may be disadvantageous when compared with the incentive splrometric device.

postoperative episodic therapy with intermittent positive-pressure breathing ( IPPB) is presently under adverse criticism, primarily because of the lack of controlled studies attesting to its clinical eflicacy 1.2 (this despite its continued useM). In addition, morbidity and even death may be associated with such therapy. 2.a.11 Alternative techniques of respiratory care include chest physiotherapy,8 resistance breathing ("blow bottles"),7 induced hyperventilation with carbon dioxide, 8 and deep-breathing maneuvers, a variant of which is called "incentive spirometry."'9 A commercially available three-ball How-measuring device ( Trifio Incentive Deep Breathing Exerciser [Trifio, Chesebrough-Pond's, Inc.]) is an inexpensive, disposable incentive spirometric device. This device is a semiquantitative How-measuring partitioned chamber containing three light balls in series, which rise successively with negative pressure and a high rate of inspiratory flow, each "ball-at-the-top" equal to 1 L/ sec during a voluntary inspiration. The purpose of this investigation was to compare daily spirometric measurements and radiologic and clinicopathologic abnormalities in postoperative patients receiving either episodic therapy with IPPB or with the incentive spirometric three-ball How-measuring device.

MATERIALS AND METHODS

From the Department of Anesthesiology, University of Miami School of Medicine, and the Veterans Administration HOSPital, Miami, Fla. ••Research Fellow. tProfessor of Anesthesiology. Manuscript received July 11; revision accepted September 12. Reprint requests: Dr. Gold, VA HOBf'Ual. 1ro1 NW 16th Street, Miami 33125 0

592 DOHI, GOLD

After informed consent had been obtained from each patient scheduled for elective intra-abdominal surgery, each received, according to a table of random numbers, either standard therapy with IPPB or with the incentive spirometric device (Trillo) for five consecutive postoperative days. Before surgery, a detailed history, including data on smoking and chronic pulmonary disease, was recorded; the latter was confirmed spirometrically. Patients with a history of ischemic heart disease or paraplegia were excluded. A registered respiratory therapist administered all treatments with IPPB using a respirator ( Bennett PR-2); each treabnent lasted 15 minutes and flow, volume, and peak inspiratory pressures were adjusted "maximally" by the therapist for each treabnent, 10 administered with the patient supine in the head-up position. The respiratory therapist also monitored the breathing maneuvers with the incentive spirometric device. After instruction in the correct use of this device on the first postaperative morning ("first exhale, maximally inhale, pursed lips on mouthpiece," etc), the patient used it five times every hour for about eight waking hours daily. For therapy with IPPB, all patients inhaled 0.5 ml of a solution (Bronkosol) containing isoetharine hydrochloride ( a bronchodilator drug) and phenylephrine hydrochloride and 4.5 ml of saline solution with each treabnent, averaging four treabnents per day; or for therapy with the incentive spirometric device, the patients inhaled the same volume and concentration via a side-arm nebulizer, agafn averaging four treabnents per day. Before therapy with the bronchodilator drug, each patient's forced expiratory volume in one second ( FEV1 ) and forced vital capacity ( FVC) were measured with a spirometer (Vitalor), and the peak expiratory flow (PEF) was measured with a Wright peak flowmeter. Three measurements were made, and the average of the highest two was recorded. This was done while the patient wore a nose clip and was sitting at bedside. Both instruments were calibrated with a spirometer (Godart), and accuracy was maintained throughout the investigation.

CHEST, 73: 5, MAY, 1978

Each patient's chronologic schedule was as follows: (I) control measurements, obtained one day before surgery; ( 2) day of surgery (no measurements); and ( 3) measurements on five consecutive postoperative days. Less than 10 percent of the patients, divided equally among both groups, missed one or two days of measurements for reasons due to patient care. All patients had preoperative chest x-ray Sims as controls. A chest x-ray film was obtained on the third postoperative day. Elevation of temperature, tachycardia, tachypnea, production of sputum, and abnormalities in chest auscultation were monitored. Atelectasis, pneumonia, pleural effusion, and bronchitis were diagnosed both radiologically (significant radiopacity) and clinically.11.12 All x-ray Sims were interpreted by a radiologist on the staff. Thirty-four patients received therapy with the incentive spirometric device, and 30 received therapy with IPPB. The analgesic regimen was limited to therapy with morphine ( 6 mg/70 kg of body weight) or meperidine ( 50 mg/70 kg) once or twice daily. No spirometric testing was done until two hours had elapsed.

fu:suLTS Table 1 lists the patients' characteristics in this series (male patients predominant), including age, height, weight, risk status according to American Society of Anesthesiologists, durations of anesthesia and nasogastric intubation, number of days when narcotic drug was administered, and preoperative spirometric values (both actual and predicted) .13•14 There were no significant differences in these characteristics between the two groups according to Student's t-test. Table 1 also lists the type of operation (upper or lower abdominal), the primary anesthetic agent, the presence or absence of chronic obstructive pulmonary disease ( COPD), and the history of smoking. All patients were intubated and paralyzed and received mechanical ventilation. There were no significant differences between the two groups, with the exception that more heavy smokers received therapy with the incentive spirometric device. The postoperative spirometric data demonstrate no statistically significant differences in daily improvement between the two groups. This is displayed in Figure 1, a composite of daily measurements of FEV1, FVC, and PEF, relating values for each postoperative day and comparing them with preoperative control values; the trend toward recovery favors the incentive spirometric device. Mean spirometric measurements severely declined on the first day after surgery and recovered steadily . through the fifth day; no variable returned to its preoperative value. Twenty-three patients had radiologic abnormalities, ie, infiltration, atelectasis, or pleural effusion (Table 2). Nine of these patients were in the group using the incentive spirometric device, and 14 were in the group receiving therapy with IPPB. CHEST, 73: 5, MAY, 1978

Table 1--Claaractemlica of Paden,.•

Data No. of patients Clinical data•• Age, yr Height, cm Weight, kg Rating of risk t Duration of anesthesia, min Duration of nasogastric intubation, days Duration of therapy with narcotic drugs, days Pulmonary data•• Preoperative FVC, L Actual Predicted 11 • u Preoperative FEV1 Actual value, L Percent of predicted Predicted value, L 11 ·u Preoperative PEF, L/min Actual Predicted11 • u Type of operation Upper abdominal Lower abdominalt Primary anesthetic agent or technique Enflurane Halothane Balanced History of COPD No Yes History of smoking Nonsmoker Ex-smoker Light-moderate ( <100 pack-years) Heavy ( > 100 pack-years)

Incentive Spirometric Therapy Therapy with IPPB 34

30

54±9 57±9 174.6±7.4 175.l ±7.4 72.2±12.9 74.1 ±13.0 2.1±0.6 2.2±0.6 233±107

247±114

3.1 ±1.8

2.6±1.7

3.4±1.3

3.3±1.4

3.37±0.67 4.01 ±0.44

3.32±0.70 3.94±0.49

2.47±0.74 72 3.18±0.36

2.36±0.71 70 3.10±0.40

434.5 ± 130.2 548.2±33.2

433.1±140.0 540.0±37.1

23 11

13 17

22

23 2 5

2 10

28 6

22

5 5

9 4

16 8§

16 1§

8

*There were 62 male and two female patients. **Mean± SD. t American Society of Anesthesiologists. tOne extra-abdominal operation in each group. §P<0.05.

There was a close relation between radiologic and clinical signs ( elevation of temperature, auscultatory abnormalities and increased production of sputum). Four patients had such abnormal clinical signs with normal radiologic findings and were diagnosed by surgeons (with medical consultation) as having "acute bronchitis." Repeat chest x-ray fihns showed no further deterioration from the third day to the fifth day; clinical signs improved in both groups. TWO METHODS OF POSTOPERATIVE RESPIRATORY CARE 593

Table 2--Pulrnoruiry Complicadoq•

500

30

Pneumonia

4 (12)

7 (23)

Atelectasis

5 (15)

7 (23)

No. of patients

200

Acute bronchitis Total complications :!: S. D.

1

+-Triflo mean -f--·IPPB mean

0 4

FVC & FEV1

__ U}Fvc I}FEv1

3

2 1 1

Pre-op. Post-op

2

3

DAY

4

5

F1cURE 1. Spirometric data from 6ve consecutive days after intra-abdominal surgery, comparing therapy with incentive spirometric device (Trillo) vs therapy with IPPB.

In Table 2, 10 ( 29 percent) of the 34 patients treated with the incentive spirometric device and 17 ( 57 percent) of the 30 patients treated with IPPB developed pneumonia, atelectasis, or "acute bronchitis" ( P < 0.051, corrected 'JC test). There was no statistically significant difierence between the two groups with respect to complications according to ·age or history of COPD (Table 3) or an FEV1 lesser or greater than 75 percent of predicted or in smokers vs nonsmokers. Differences in the site of surgery and the type and duration of anesthesia were not significant between the two groups with respect to complications. · · DISCUSSION

"Incentive spirometric" therapy via the commercial device that we used ( Trlllo) is equal spirometrically to therapy with IPPB. The clinical evidence favored the patients treated with the incentive spirometric device (rate of complications approximately 29 percent vs 57 percent). Of the 34 patients treated with the incentive spirometric device, 10 developed postoperative pulmonary complications, while 17 of the 30 patients treated with IPPB de584 DOHI, GOLD

34

Complication

l/min

0

Therapy with IPPB

PEF

400

liters

Incentive Spirometric Therapy

1 (3) 10 (29) ..

3 (10) 17 (57) ..

values are numbers of patients; numbers within parentheses are percentages. ..P<0.051. ~able

veloped such complications. Our patients were elderly, most smoked, and all had undergone intraabdominal surgery (a significant number with upper abdominal surgery). This was, therefore, a series of patients who were prone to respiratory complications.15 Although the data favor the incentive spirometric device over !PPB, the statistical significance is thin (P < 0.051). We believe that these data represent a "trend" and not a conclusion. The use of the incentive spirometric device is justified over episodic therapy with IPPB because, at the least, the two are "therapeutically" equal, and the former is much cheaper. Episodic therapy with IPPB costs $1' billion to $2 billion annually; 18 its postoperative use represents a significant fraction of this. From a fiscal standpoint, therapy with four treatments of IPPB daily for spurious reasons, 1 costing up to $100 daily, 17 is much more expensive than therapy with the incentive spirometric device (Triffo), costing less than $10 once. Table 3--Plllrnontay Complicado,.. and Preoperali'lle Conclidon •

Data No. of patients with complications

Incentive Spirometric Therapy

Therapy with IPPB

10/34

17/30

FEV., percent of predicted >75 percent <75 percent

7/17 3/17

8/13

Smoking history Nonsmoker or ex-smoker Smoker

5/.10 5/24

6/13 11/17

History of COPD No Yes

8/28 2/6

11/22 6/8

Age <60yr >60yr

8/27 2/7

11/21 6/9

9/17

values are numbers of patients with complications out of number in group.

~able

CHEST, 73: 5, MAY, 1978

With encouragement by nurses, physicians, and respiratory therapists, improvement in the use of the incentive spirometric device motivates the patient who often has insight into and appreciates the hourto-hour change. While some patients feel better after therapy with IPPB, l.2 the interval of four to six hours between treatments may not be therapeutically equal to the hourly self-treatments throughout the day with the incentive spirometric device, which also provides similar subjective improvement. The spirometric data reveal no significant difference between the two therapeutic methods. On the first postoperative day, pain, discomfort, and narcosis are highest. 15•18 Spirometric results improve as discomfort declines, the wound heals, and ambulation occurs. Perhaps the deep breathing five times per hour exercises and strengthens the diaphragm, a characteristic lacking in passive episodic therapy with IPPB. 8 This decreases, not increases, the maximum differences in intrapleural pressure. Since 1970, when incentive spirometry was initiated, other studies involving deep breathing on a voluntary basis have favored it. 18 Its "star" is rising while that of therapy with IPPB declines. 2..20 Strengthening the diaphragm, a voluntary striated muscle, may overcome the tendency for the functional residual capacity to fall8•15.21 and for the closing capacity to rise. This may also improve the mechanism for coughing and the ability to raise secretions. The benefit clinically appears to be a decreased incidence of atelectasis and pneumonia and an increase in "alveolar recruitment."B.1 2.22 ACKNOWLEDGMENT: We thank Miss Albia Dugger for technical help and suggestions.

1 Baxter, WO, Levine RS: An evaluation of intermittent positive pressure breathing in the prevention of postaperative pulmonary complications. Arch Surg 98:795798, 1969 2 Gold MI: Is intermittent positive pressure breathing therapy ( IPPB Rx) necessary in the surgical patient? Ann Surg 184:122-123, 1976 3 Browner B, Powers SR Jr: Effect of IPPB on functional residual capacity and blood gases in postoperative patients. Surg Forum 26:96-98, 1975 4 Murray JF: Review of the state of the art in intermittent positive pressure breathing therapy. Am Rev Respir Dis 110:193-199, 1974

CHEST, 73: 5, MAY, 1978

5 Sanders CV Jr, Luby JP, Johanson WG, et al: Serratia marcescens infections from inha1ation therapy medications: nosocomial outbreak. Ann Intern Med 73:15-21, 1970 6 Thoren L: Postoperative pulmonary complications: Observations on their prevention by means of physiotherapy. Acta Cbir Scand 107: 193-205, 1954 7 Colgan FJ, Mahoney PD, Fanning GL: Resistance breathing (blow bottles) and sustained hyperinflations in the treatment of atelectasis. Anesthesiology 32:543-550, 1970 8 O'Conner MJ: Comparison of two methods of postaperative pulmonary care. Surg Gynecol Obstet 140:615-617, 1975 9 Bartlett RH, Hanson EL, Moore FD: Physiology of yawning and its application to postoperative care. Surg Forum 21 :222-224, 1970 10 Sheldon GP: IPPB: Yes or noP (letter to editor). Chest 69:133-136, 1976 11 Laszlo G, Archer GG. Darrell JH: The diagnosis and prophylaxis of pulmonary complications of surgical operation. Br J Surg 60:129-134, 1973 12 Craven JL, Evans GA, Davenport PJ: The evaluation of the incentive spirometer in the management of postoperative pulmonary complications. Br J Surg 61:793-797, 1974 13 Ferris BG Jr, Anderson DO, Zickmantel R: Prediction values for screening tests of pulmonary function. Am Rev Respir Dis 91:252-261, 1965 14 Leiner CC, Abramowitz S, Small MJ: Expiratory peak flow rate: Standard values for normal subjects: Use as a clinical test of ventilatory function. Am Rev Respir Dis 88:644-651, 1963 15 Latimer RG, Dickman M, Day WC, et al: Ventilatory patterns and pulmonary complications after upper abdominal surgery determined by preoperative and postoperative computerized spirometry and blood gas analysis. Am J Surg 122:622-632, 1971 16 Leith DE: Conference on the scientific basis of respiratory therapy: Review of comments concerning presentations and discussions of the intermittent positive pressure breathing session. Am Rev Respir Dis 110:200-200, 1974 17 Baker JP: Magnitude of usage of intermittent positive pressure breathing. Am Rev Respir Dis 110:170-177, 1974 18 Palmer KNV: Pulmonary function in the surgical patient. Postgrad Med J 42:421-427, 1966 19 Bartlett RH, Gazzaniga AB, Geraghty TR: Respiratory maneuvers to prevent postoperative pulmonary complications: A critical review. JAMA 224:1017-1021, 1973 20 Wright FG Jr, Foley MF, Downs JB, et al: Hypoxemia and hypocarbia following intermittent positive-pressure breathing. Anesth Analg (Cleve) 55:555-559, 1976 21 Alexander JI, Spence AA, Parikh RIC, et al: The role of airway closure in postoperative hypoxia. Br J Anaesth 45:34-40, 1973 22 Van De Water JM, Watring WG, Linton LA, et al: Prevention of postaperative pulmonary complications. Surg Gynecol Obstet 135:229-233, 1972

TWO METHODS OF POSTOPERATIVE RESPIRATORY CARE 595