European Journal of Cardiovascular Medicine

Respiratory exercise and flow breathing spirometer is an exercise of importance for patients with upper abdominal surgery. The beneficial effects of deep breathing include; inflation in the alveoli, reversing postoperative hypoxia, improving ventilation and oxygenation, reducing breathing action, and increasing flight degree of the diaphragm [5].The incentive spirometry technique was used to encourage the patient to take maximum and long inspiration, and slow deep breathing using a device to measure flow or sound.

Chest physiotherapy is a common practice in patients undergoing cardiothoracic and abdominal surgery. Abdominal surgery that was previously performed via a large incision is now more commonly performed laparoscopically.

In laparoscopy, intraoperative pulmonary changes are due to decreased pulmonary compliance secondary to upward movement of the diaphragm during insufflation and to changes in carbon dioxide (co2) homeostasis secondary to absorption of insufflated co2 from peritoneum.Studies have reported altered pulmonary function after both conventional and laparoscopic abdominal surgeries [2-4].

Pulmonary dysfunction leads to pulmonary complications which include atelectasis, pneumonia, tracheobronchial infection, and respiratory failure. These may have an adverse effect on the length of hospital stay. The beneficial effects of deep breathing are as follows: inflation of the alveoli, reversing postoperative hypoxemia, improvement of ventilation and oxygenation, decreasing the work of breathing, and increasing the degree of excursion of the diaphragm [5, 6].

Pulmonary dysfunction leads to pulmonary complications which include atelectasis, pneumonia, tracheobronchial infection, and respiratory failure. These may have an adverse effect on the length of hospital stay. The beneficial effects of deep breathing are as follows: inflation of the alveoli, reversing postoperative hypoxemia, improvement of ventilation and oxygenation, decreasing the work of breathing, and increasing the degree of excursion of the diaphragm [5, 6].

Mechanical breathing device such as the incentive spirometry has been introduced into clinical practice [7]. Incentive spirometry encourages the patient to take long, slow deep breath mimicking natural sighing and also provides a visual positive feedback. With this background the present study aim is to compare the effect of deep breathing exercise, flow and volume incentive spirometry, on pulmonary function and diaphragm excursion, following laparoscopic surgery.             

INCLUSION CRITERIA

Inclusion criteria will involve

1) Subjects of either gender.

2) Age group of 25 to 55 years

3) Elective laparoscopic cholecystectomy.

EXCLUSION CRITERIA

1. Patients with unstable hemodynamic parameters (arterial pressure <100 mmHg systolic and <60 mmHg for diastolic and mean arterial pressure (MAP) <80 mmHg).
2. Patients with postoperative complications requiring mechanical ventilation.
3. Patients with inadequate inspiration characterized by vital capacity <10 mL/kg.
4. Patients who had history of open abdominal surgery and laparoscopic obstetrics and gynecological surgery.

The study was carried out in S.N Medical College, Agra, starting from December 2016 to September 2018.Eligible patients were selected based on the inclusion and exclusion criteria. The purpose of study made clear to each patient and a written informed consent taken prior to involving them in the study. Randomization carried out by using sealed envelope method.

The patients were divided into three groups:

• Group A (DBE): Deep breathing exercise group.
• Group B (FIS): Flow-oriented incentive spirometry group (Triflow device).
• Group C: (Control group) (those who are unable to understand the intervention procedure and those who refuse to do any intervention are included in control group)

Method to perform deep Breathing Exercise

The patient will be in semi-Fowler's position (back and head are fully supported and abdominal wall is relaxed) and perform deep breathing. The therapist will place his hands just below the anterior costal margin, on the rectus abdominals, while the patient instruct to inhale slowly and deeply through the nose, from functional residual capacity to total lung capacity with a three-second inspiratory hold. The patient will be then instruct to relax the shoulders, keep the upper chest quiet in order that the abdomen be raised a little. The Patient then instructs to exhale slowly through the mouth [3].

The Patient will make to experience a slight rise and subsequent fall of the abdomen during inspiration and expiration, by placing his or her own hand below the anterior costal margin. The Patient will be instruct to perform 3 sets of 5 deep breaths with the therapist administering them four times a day and the patient being instruct to perform the same once every four waking hour for the rest of the day. In between the repetitions of the diaphragmatic breathing exercise, the patient was told to breathe normally [8].

Methods to Perform Incentive Spirometry

The patient will be in a semirecumbent position (45°), with a pillow under the knees. The patient will be instructed to inhale with a slow and deep sustained breath, holding it for a minimum of 5 seconds and then to exhale passively in order to avoid any forceful expiration. First, the patient will be given demonstration and then ask to perform in order to ensure that she/he understood the process [1]. The patient will be instructed to hold the spirometer upright and to perform flow-oriented incentive spirometry by inhaling slowly and thereby raising the ball. The patient will be instructed to perform 3 sets of 5 repeated deep breaths. This will be performed by the patient every four hour. The therapist administers the exercise four times a day and the patient will be instructed to perform the same for the rest of the day [1]. The patient will ask to keep a record of the exercise performed by entering in a log book which will be provided beforehand.

Procedure

120 patients (of either sex) aged 25-55   years and who were to undergo elective laparoscopic cholecystectomy at S.N.M.C. hospital surgery department participated in the study. The rationale and procedures for the study were explained to the subjects and their consent was obtained. Subject who met the inclusion criteria were assigned to either group A, B or C. Predicted values for pulmonary function tests were related to age, sex, height & weight according to the normal values reported.

Pulmonary function tests (PFT) measured the following variables: Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), Peak Expiratory Flow Rate (PEFR). These were taken on the preoperative day Day1, 1st and the 2nd postoperative day, for all groups, day 2 and 3 respectively.

Forced Vital Capacity (FVC) was compared within intervention groups and the control group before and after laparoscopic cholecystectomy and is summarized in Table 1A, 1B.

Table 1(a): Comparison of Forced Vital Capacity (FVC) before and after the laparoscopic abdominal Surgery in the intervention groups and control group.

Table 1(b): Comparison of mean difference and percentage change in Forced Vital Capacity (FVC) before and after the laparoscopic abdominal surgery in the intervention groups and control group.

There was a statistically significant decrease in Forced Vital Capacity (FVC) in the 1st and 2nd post-operative day when compared with the preoperative period in all groups. The mean difference in values between the preoperative and the 1st postoperative day in the Deep Breathing Exercise group was 0.57 (21.11%),the Flow Incentive Spirometry group was 0.67 (25.19%),  and in the control group was 0.85 (37.78%).The mean difference in values between the preoperative and the 2nd postoperative day in the Deep Breathing Exercise group was 0.26 (9.63%), the Flow Incentive Spirometry group was 0.28 (10.5%), and in the control group was 0.35 (15.5%).

The mean difference between the 1st postoperative day and the 2nd postoperative day in the Deep Breathing Exercise group was -0.31 (-14.55%), the Flow Incentive Spirometry group was -0.39 (-19.6%), and the control group was -0.50 (-35.71%).Forced Expiratory Volume in one second (FEV1) were compared with in the intervention groups and the control group before and after laparoscopic cholecystectomy, as summarized in Table 2A, 2B.

Table 2(a): Comparison of Forced Expiratory Volume in one second (FEV1) before and after the laparoscopic abdominal surgery in the intervention groups and control group.

Table 2(b): Comparison of mean difference and percentage change in Forced Expiratory Volume in one second (FEV1) before and after the laparoscopic abdominal surgery in the intervention groups and control group.

In all groups there was a statistically significant decrease in Forced Expiratory Volume at the end of the first second (FEV1) on the 1st and 2nd post-operative day when compared to the preoperative period. The mean difference in FEV1 between the preoperative and the 1st postoperative day in the Deep Breathing Exercise group was 0.89 (3.72%), the Flow Incentive Spirometry group was 0.64 (30.33%), and in the control group was 0.84 (37.17%).The mean difference in FEV1 between the preoperative and 2nd the postoperative day in the Deep Breathing Exercise group was 0.44 (16.48%),the Flow Incentive Spirometry group was 0.31 (14.70%),  and in the control group was 0.38 (16.81%).

The mean difference between the 1st postoperative day and the 2nd postoperative day in the Deep Breathing Exercise group was -0.45 (-26.01%), the Flow Incentive Spirometry group was -0.33 (-22.45%), and in the control group was -0.46 (-32.39%).Peak Expiratory Flow Rate (PEFR) were compared with in intervention groups and control group before and after laparoscopic cholecystectomy and is summarized in Table 3A, 3B.

Table 3(a): Comparison of Peak Expiratory Flow rate (PEFR) before and after the laparoscopic abdominal surgery in the intervention groups and the control group.

Table 3(B): Comparison of mean difference and percentage change in   Peak Expiratory Flow rate (PEFR) before and after the laparoscopic abdominal surgery in the intervention groups and the control group.

In all groups there was a statistically significant decrease in peak expiratory flow rate (PEFR) on the 1st and 2nd post-operative day as compared to the preoperative period. The mean difference the between preoperative and the 1st postoperative day in the Deep Breathing Exercise group was 1.58 (28.73%), the Flow   Incentive Spirometry group was 2.11(38.64%), the and in the control, group was 1.65 (31.25%). The mean difference between the preoperative and the 2nd postoperative day in the Deep Breathing Exercise group was 0.80 (14.55%), the Flow Incentive Spirometry group was 1.16 (21.25%), and in the control group was 1.02 (19.32%). The mean difference between the 1st postoperative day and the 2nd postoperative day in the Deep Breathing Exercise group is -0.78 (-19.90%), the Flow Incentive spirometry group was -0.95 (-28.36%), and in the control group was -0.63(-17.36%).

The mean difference the between preoperative and the 1st postoperative day in the Deep Breathing Exercise group was 0.15 (15.31%), the Flow   Incentive Spirometry group was 0.05(6.25%), the and in the control, group was 0.01(0.97%). The mean difference between the preoperative and the 2nd postoperative day in the Deep Breathing Exercise group was 0.08 (8.16%), the Flow Incentive Spirometry group was 0.04 (5.00%), and in the control group was 0.01 (0.97%).

The mean difference between the 1st postoperative day and the 2nd postoperative day in the Deep Breathing Exercise group is -00.07 (-8.43%), the Flow Incentive spirometry group was -0.01 (-1.33%), and in the control group was 0.02(1.92%).

The main purpose of this study is to compare deep breathing exercise, Flow incentive spirometry on pulmonary function in patients undergoing laparoscopic cholecystectomy surgery. There were 40 patients included in each group and there are three groups, and all three groups are homogenous in terms of all demographic parameters. In our study we found that deep breathing exercise and incentive spirometry improve lung function in patients undergoing laparoscopic cholecystectomy surgery. During the postoperative period, patients exhibit shallow breathing without the intermittent sigh or breaths which are inspired approximately ten times an hour.

Patients will breathe shallow leads to a decrease ventilation to dependent lung Regions [9]. In the present study, reduced pulmonary function (FVC, FEV1 and PEFR) in postoperative laparoscopic cholecystectomy surgery subjects might be due to postoperative pain, location of surgical ports, along with anaesthetic, analgesic usage [10]

The effects of general anaesthesia on distribution of ventilation, and chest wall and lung mechanics leads to ventilation-perfusion mismatch, increased dead space, shunt and hypoxemia. [11,12]

The location of surgical ports involves trauma near the diaphragm and chest wall/ribs, leading to postoperative incisional pain and reflex inhibition of the phrenic nerve and diaphragmatic reflex paresis resulting in functional disruption of respiratory muscle movement. In addition, when patients remain lying down for long periods during the postoperative period their abdominal content limits diaphragmatic movement.[13]

The difference in Peak Expiratory Flow Rate (PEFR) between the preoperative and the 2nd post-operative day of patients in the deep breathing exercise group (14.55%;) and   was found to be significantly less than those in the flow -incentive spirometry group (21.25%; ) and the control group (19.32%).

In our study, the deep breathing exercise group showed a significant improvement in pulmonary function {Forced Vital Capacity [FVC] (14.55 %;), Forced Expiratory Volume in one second [FEV1] (26.01%;), Peak Expiratory Flow Rate [PEFR] (19.90;)} on the 2nd postoperative day when compared to the 1st postoperative day.

Pulmonary function (FVC, FEV1, and PEFR) in all experimental groups showed a greater improvement from the 1st postoperative to the 2nd postoperative day than was observed in the control group.

To summarized, systematically compared the effects of breathing techniques on pulmonary function in subjects undergone laparoscopic surgery and it was found that pulmonary function was found to be better preserved in the deep breathing exercise group and incentive spirometry group when compared to the pulmonary function in control group.

In our study pulmonary function (FVC, FEV1, and PEFR) and in the intervention groups (deep breathing exercise and incentive spirometry group) was nearly equivalent to those of the preoperative values when compared to the control group.

Our results are in accordance with the findings of Tahir et al. who showed that deep breathing exercise will improve basal ventilation. Webber and Menkes et al. found that diaphragmatic breathing exercise will improve tidal volume and also facilitate secretion removal. [14]. Webber and Menkes et al. found that diaphragmatic breathing exercise will improve tidal volume and also facilitate secretion removal.[14]

Form our study we conclude that –

There is a significant decrease in pulmonary function {Forced Vital Capacity (FVC), Force Expiratory Volume in the first one second (FEV1), Peak Expiratory Flow Rate (PEFR)} and on the 1st postoperative day when compared to the pre-operative day in laparoscopic cholecystectomy surgery patients.

There is a significant decrease in pulmonary function {Forced Vital Capacity (FVC), Force Expiratory Volume in the firstone second (FEV1) and Peak Expiratory Flow Rate (PEFR)} on the 2nd postoperative day when compared to the pre-operative day in laparoscopic cholecystectomy surgery patients.

According to our study pulmonary function (FVC, FEV1, and PEFR) in all experimental groups (Flow Incentive Spirometry group and deep Breathing Exercise group) showed a greater improvement than the control group on 2nd postoperative day in comparison to the 1st postoperative day.

1. Carvalho CRF, Paisani DM., Lunardi AC. Incentive spirometry in major surgeries: a systematic review. Brazilian Journal of Physical Therapy. 2011; 15:343–50.
2. Ravimohan SM, Kaman L, Jindal R, Singh R, Jindal SK. Postoperative pulmonary function in laparoscopic versus open cholecystectomy: A prospective, comparative study. Indian Journal of Gastroenterology. 2005; 24:6–8.
3. Frazee RC, Roberts JW, Okeson GC. Open versus laparoscopic cholecystectomy. A comparison of postoperative pulmonary function. Am J Surg. 1991; 213:651–54.
4. Schauer PR, Luna J, Ghiatas AA. Pulmonary function after laparoscopic cholecystectomy. Surgery. 1993; 114:389–99.
5. Grams ST, Ono LM, Noronha MA, Schivinski CIS, Paulin E. Breathing exercises in upper abdominal surgery: a systematic review and meta-analysis. Brazilian Journal of Physical Therapy. 2012; 16:345–53.
6. El-Marakby AA, Darwiesh A, Anwar E, Mostafa A, Jad A. Aerobic exercise training and incentive spirometry can control postoperative pulmonary complications after laparoscopic cholecystectomy. Middle East Journal of Scientific Research. 2013; 13:459–63.
7. Chuter TAM, Weissman C, Mathews DM, Starker PM. Diaphragmatic breathing manoeuvres and movement of the diaphragm after cholecystectomy. Chest. 1990; 97:1110–14.
8. Weber BA, Prayar J. Physiotherapy skills: techniques and adjuncts. In Webber BA, Prayar J, editor.Physiotherapy for respiratory and cardiac problems; Edinburgh Churchill living stone 1993:113-71.
9. Bhat S, Katoch L, Kalsotra L, Chrungoo RK. A Prospective Comparative Trial of Post -Operative Pulmonary Function: Laparoscopic versus Open Cholecystectomy. J K Science 2007; 9:83-6.
10. Ali J, Weisel RD, Layug AB, Kripke BJ, Hechtman HB. Consequences of postoperative alterations in respiratory mechanics. Am J Surg 1974; 128:376-2.
11. Wahba RW. Perioperative functional residual capacity. Can J Anaesth 1991; 38:384-400.
12. Weissman C. Perioperative respiratory physiology. J Crit Care 1991; 6:160-71.
13. Ramos GC1, Pereira E, Gabriel Neto S, Oliveira EC. Pulmonary function after laparoscopic cholecystectomy and abbreviated anesthetic-surgical time. Rev Col Bras Cir. 2009; 36:307-11.
14. Menkes HA, Britt J. Rationale for physical therapy. American review of respiratory disease.122:127-31.