The Influences of Positive End Expiratory Pressure (Peep) Associated With Physiotherapy Intervention in Phase I Cardiac Rehabilitation

Abstract

PURPOSE:To evaluate the effects of positive end expiratory pressure and physiotherapy intervention during Phase I of cardiac rehabilitation on the behavior of pulmonary function and inspiratory muscle strength in postoperative cardiac surgery. METHODS: A prospective randomized study, in which 24 patients were divided in 2 groups: a group that performed respiratory exercises with positive airway expiratory pressure associated with physiotherapy intervention (GEP, n = 8) and a group that received only the physiotherapy intervention (GPI, n = 16). Pulmonary function was evaluated by spirometry on the preoperative and on the fifth postoperative days; inspiratory muscle strength was measured by maximal inspiratory pressure on the same days. RESULTS: Spirometric variables were significantly reduced from the preoperative to the fifth postoperative day for the GPI, while the GEP had a significant reduction only for vital capacity (P < .05). When the treatments were compared, smaller values were observed in the GPI for peak flow on the fifth postoperative day. Significant reductions of maximal inspiratory pressure from preoperative to the first postoperative day were found in both groups. However, the reduction in maximal inspiratory pressure from the preoperative to the fifth postoperative day was significant only in the GPI (P < .05). CONCLUSIONS: These data suggest that cardiac surgery produces a reduction in inspiratory muscle strength, pulmonary volume, and flow. The association of positive expiratory pressure with physiotherapy intervention was more efficient in minimizing these changes, in comparison to the physiotherapy intervention alone. However, in both groups, the pulmonary volumes were not completely reestablished by the fifth postoperative day, and it was necessary to continue the treatment after hospital convalescence. Cardiac surgery reverts symptoms for individuals with specific cardiopathologies and measurably increases their chances of survival and quality of life.1-3 However, pulmonary complications are quite frequent and represent an important cause of morbidity and mortality for patients undergoing cardiac surgery with cardiopulmonary bypass. 2,[4][5][6] These patients can develop various degrees of a systemic inflammatory response syndrome due to factors such as surgical trauma, contact of blood with nonendothelial surfaces of the bypass circuit, and alterations known as reperfusion post-cardiopulmonary bypass lesions, mainly affecting the cardiac and pulmonary regions. 2,[4][5][6] In the pulmonary region, there is an increase in extravascular water with alveolar filling caused by inflammatory cells, which leads to the inactivation of the pulmonary surfactant and collapse of some areas, modifying the pulmonary ventilation/perfusion relationship, with resultant

Fisioterapia respiratória na disfunção pulmonar pós-cirurgia cardíaca

“…Borghi-Silva [29] found better recovery of pulmonary function in the group that used PEP associated with DBEs and early mobilization (n=8), when compared to DBE and early mobilization alone (n=16). The authors noted that the use of PEP was more effective in restoring inhalation muscle strength.…”

“…All trials included had samples larger than 20 patients. Among the studies included, incentive spirometry (IS) was performed in three of them [20,24,27], deep breathing exercises (DBE) were used in six [20,21,23,[28][29][30]; DBE associated with positive expiratory pressure (PEP) was used in four [21,22,28,29] and PEP associated with respiratory resistance (PEP-IR) was used in two [21.28]. Breathing with intermittent positive pressure (BIPP) was used in three studies [25,27,30]; continuous positive airway pressure (CPAP) was used in two [24 , 26], bi-level positive airway pressure (BiPAP) was used in three studies [24][25][26].…”

“…Westerdahl et al [21] restricted the studied population to males. Three studies [22,29,30] reported the inclusion of patients who underwent HS, not specifying the type of performed surgeries. Brasher et al [23] included patients who underwent coronary artery bypass grafting (CABG) and valve replacement.…”

“…In one study [24], IS was associated with less favorable results in the improvement of VC, FEV1 and PaO2 when compared to other techniques (CPAP and BiPAP). In another randomized clinical trial [20], the addition of IS to respiratory physiotherapy (DBE, early mobilization and techniques of [20] / 1997/ RCT Matte et al [24] / 2000/ RCT Westerdahl et al [21] / 2001/ RCT Brasher et al [23] / 2003/ RCT Westerdahl et al [28] / 2003/ RCT Pasquina et al [26] / 2004/ RCT Borghi-Silva et al [29] / 2005/ RCT Westerdahl et al [22] / 2005/ RCT Mendes et al [30] / 2006/ RCT Muller et al [25] bronchial hygiene) was not more effective than the respiratory physiotherapy alone in reducing the occurrence of pulmonary complications, the length of hospital stay, radiological pulmonary function or SatO 2 improvement. In the early days of PO HS, the use of such resources was associated with greater difficulty in lung expansion due to restrictive factors such as pain [27], with questionable potential to prevent subsequent damage in lung function [24].…”

“…The analyzed variables included pulmonary oxygenation (oxygen saturation -SatO 2 , partial pressure of oxygen in arterial blood -PaO 2 , oxygenation index -PaO 2 / FiO 2 ) [20,[22][23][24][25][26][27][28]; lung function measured by spirometry (forced expiratory volume in the first second -FEV1, vital capacity -VC, forced vital capacity -FVC, peak expiratory flow -PEF, forced expiratory flow between 25 and 75% of FVC -FEF 25-75%) [20][21][22]24,26,29,30]; chest x-rays, including signs of atelectasis [20,21,23,24,26]; time of hospital stay [20,23]; rates of lung infection [20.23], respiratory muscle strength (maximum inspiratory pressure -MIP, and maximal expiratory pressure -MEP) [27,29,30]. Two of the included studies analyzed the results of thoracic computed tomography (TCT) [22.28].…”