Chest physiotherapy does not improve the outcome in laparoscopic fundoplication and vertical-banded gastroplasty Pre-operative short-term pulmonary rehabilitation for patients of chronic obstructive pulmonary disease undergoing coronary artery bypass graft surgery. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. The influences of positive end expiratory pressure (PEEP) associated with physiotherapy intervention in phase I cardiac rehabilitation. Effects of preoperative inspiratory muscle training in obese women undergoing open bariatric surgery: respiratory muscle strength, lung volumes, and diaphragmatic excursion [Prevention of postoperative pulmonary complications after heart-lung surgery. Comparison of 3 different mask physiotherapy regimens]. Randomized controlled trial of physiotherapy for postoperative pulmonary complications. Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Postoperative pulmonary complications in upper abdominal surgery. A randomized clinical comparison between physiotherapy and blow-bottles. Feasibility of preoperative inspiratory muscle training in patients undergoing coronary artery bypass surgery with a high risk of postoperative pulmonary complications: a randomized controlled pilot study Effect of a Preoperative Intervention on Preoperative and Postoperative Outcomes in Low-Risk Patients Awaiting Elective Coronary Artery Bypass Graft Surgery Three different mask physiotherapy regimens for prevention of post-operative pulmonary complications after heart and pulmonary surgery Effects of an inspiratory muscle rehabilitation program in the postoperative period of cardiac surgery. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques Postoperative pulmonary complications and lung function in high‐risk patients: a comparison of three physiotherapy regimens after upper abdominal surgery in general anesthesia Short-term effects of inspiratory muscle training in coronary artery bypass graft surgery: A randomized controlled trial Respiratory muscle training in patients submitted to coronary arterial bypass graft. Prevention of pulmonary complications after upper abdominal surgery by preoperative intensive inspiratory muscle training: a randomized controlled pilot study Patient mortality in the 12 years following enrolment into a pre-surgical cardiac rehabilitation programme [Mask physiotherapy for prevention of pulmonary complications after heart surgery. A controlled study]. Mask physiotherapy in patients after heart surgery: A controlled study Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery Effects of Inspiratory Muscle Training on Muscular and Pulmonary Function After Bariatric Surgery in Obese Patients Empirical evaluation of very large treatment effects of medical interventions. Pre- and Postoperative Cardiopulmonary Rehabilitation in Hospitalized Patients Undergoing Coronary Artery Bypass Surgery: A Randomized Controlled Trial [Fewer lung complications following inspiratory muscle training in patients undergoing coronary bypass surgery: a randomized trial]. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. The effect of physical therapy on respiratory complications following cardiac valve surgery. Pre-operative inspiratory muscle training preserves postoperative inspiratory muscle strength following major abdominal surgery - a randomised pilot study. [Prophylactic inspiratory muscle training before coronary artery bypass graft]. Pulmonary function and physical performance outcomes with preoperative physical therapy in upper abdominal surgery: a randomized controlled trial The prevention of pulmonary complications after upper abdominal surgery in patients with noncompromised pulmonary status. Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial. Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study. Comparison of Two Preoperative Inspiratory Muscle Training Programs to Prevent Pulmonary Complications in Patients Undergoing Esophagectomy: A Randomized Controlled Pilot Study Preoperative therapeutic programme for elderly patients scheduled for elective abdominal oncological surgery: a randomized controlled pilot study Prophylactic Inspiratory Muscle Training in Patients Undergoing Coronary Artery Bypass Graft
Abstract Background : Chest physiotherapy is a common practice after open reflux and obesity surgery . It is now possible to perform fundoplication and vertical b and ed gastroplasty ( VBG ) by the laparoscopic technique . The aim of this study was to evaluate in a prospect i ve , r and omized , controlled trial whether chest physiotherapy affects the postoperative course . Method : A series of 40 patients underwent laparoscopic fundoplication ; another 40 underwent laparoscopic VBG .  Twenty patients in each series received prophylactic chest physiotherapy ; the other 20 served as control patients and were not given any information or training . Results : Postoperatively , all patients had a significant reduction in respiratory function , measured as oxygen saturation , forced vital capacity , and peak expiratory flow , but the differences between the groups within each series were not significant . Postoperatively , one patient in the VBG treatment group had hypoxemia ( SaO2 < 92 % ) versus two control patients . One control patient developed postoperative pneumonia . Conclusions : This study indicates that routine chest physiotherapy is not necessary in patients undergoing laparoscopic upper gastrointestinal surgery , such as fundoplication and VBG The role of pre-operative short-term pulmonary rehabilitation in patients with chronic obstructive pulmonary disease who undergo coronary artery bypass graft surgery has been assessed for the first time prospect ively . Forty-five patients posted for coronary artery bypass graft surgery  were r and omised to receive either short-term pulmonary rehabilitation ( group I ) or no such programme ( group II ) . Patients of both the groups were evenly matched with respect to age , sex , body surface area , duration and severity of chronic obstructive pulmonary disease and coronary artery disease . Normal individuals who evenly matched with the study group were assessed for normal respiratory function parameters . Pre-operative and post-operative peak expiratory flow rate , inspiratory capacity , post-operative ventilation time , post-operative pulmonary complication and hospital stay were determined in both the groups . Peak expiratory flow rate ( 220.0 + /- 12.9 and 324.3 + /- 84.3 in group I , 218.0 + /- 16.4 and 260.5 + /- 35.2 in group II ) and inspiratory capacity ( 844.0 + /- 147.4 and 1100.0 + /- 158.1 in group I , 830.0 + /- 117.4 and 1090 + /- 137 in group II ) were significantly lower before and after surgery respectively in both groups compared to normal values . Even though both groups showed a significant rise in post-operative peak expiratory flow rate and inspiratory capacity after surgery , the post-operative peak expiratory flow rate and inspiratory capacity in group I was significantly higher than in group II . In group I , the post-operative ventilation time ( 24.5 + /- 6.00 hours ) , post-operative complications ( n = 4 ) and hospital stay ( 12.4 + /- 3.6 days ) were significantly lower than in group II ( 35.2 + /- 22.3 hours , n = 11 , 18.8 + /- 6.6 days respectively ) . These data suggest that short-term pulmonary rehabilitation is feasible and effective in improving pulmonary functions before and after surgery and in reducing surgical morbidity and cost of medical care significantly CONTEXT Postoperative pulmonary complications ( PPCs ) after coronary artery bypass graft ( CABG ) surgery are a major source of morbidity and mortality , and increase length of hospital stay and re source utilization . The prehospitalization period before CABG surgery may be used to improve a patient 's pulmonary condition . The efficacy of preoperative inspiratory muscle training ( IMT ) in reducing the incidence of PPCs in high-risk patients undergoing CABG surgery has not yet been determined . OBJECTIVE To evaluate the prophylactic efficacy of preoperative IMT on the incidence of PPCs in high-risk patients scheduled for elective CABG surgery . DESIGN , SETTING , AND PATIENTS A single-blind , r and omized clinical trial conducted at the University Medical Center Utrecht , Utrecht , the Netherl and s , with enrollment between July 2002 and August 2005 . Of 655 patients referred for elective CABG surgery , 299 ( 45.6 % ) met criteria for high risk of developing PPCs , of whom 279 were enrolled and followed up until discharge from hospital . INTERVENTION Patients were r and omly assigned to receive either preoperative IMT ( n = 140 ) or usual care ( n = 139 ) . Both groups received the same postoperative physical therapy . MAIN OUTCOME MEASURES Incidence of PPCs , especially pneumonia , and duration of postoperative hospitalization . RESULTS Both groups were comparable at baseline . After CABG surgery , PPCs were present in 25 ( 18.0 % ) of 139 patients in the IMT group and 48 ( 35.0 % ) of 137 patients in the usual care group ( odds ratio [ OR ] , 0.52 ; 95 % confidence interval [ CI ] , 0.30 - 0.92 ) . Pneumonia occurred in 9 ( 6.5 % ) of 139 patients in the IMT group and in 22 ( 16.1 % ) of 137 patients in the usual care group ( OR , 0.40 ; 95 % CI , 0.19 - 0.84 ) . Median duration of postoperative hospitalization was 7 days ( range , 5 - 41 days ) in the IMT group vs 8 days ( range , 6 - 70 days ) in the usual care group by Mann-Whitney U statistic ( z = -2.42 ; P = .02 ) . CONCLUSION Preoperative IMT reduced the incidence of PPCs and duration of postoperative hospitalization in patients at high risk of developing a pulmonary complication undergoing CABG surgery . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N17691887 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 prospect i ve r and omized 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 OBJECTIVE : To determine whether preoperative inspiratory muscle training is able to attenuate the impact of surgical trauma on the respiratory muscle strength , in the lung volumes , and diaphragmatic excursion in obese women undergoing open bariatric surgery . DESIGN : R and omized controlled trial . SETTING : Meridional Hospital , Cariacica/ES , Brazil . SUBJECTS : Thirty-two obese women undergoing elective open bariatric surgery were r and omly assigned to receive preoperative inspiratory muscle training ( inspiratory muscle training group ) or usual care ( control group ) . MAIN MEASURES : Respiratory muscle strength ( maximal static respiratory pressure – maximal inspiratory pressure and maximal expiratory pressure ) , lung volumes , and diaphragmatic excursion . RESULTS : After training , there was a significant increase only in the maximal inspiratory pressure in the inspiratory muscle training group . The maximal expiratory pressure , the lung volumes and the diaphragmatic excursion did not show any significant change with training . In the postoperative period there was a significant decrease in maximal inspiratory pressure in both the groups . However , there was a decrease of 28 % in the inspiratory muscle training group , whereas it was 47 % in the control group . The decrease in maximal expiratory pressure and in lung volumes in the postoperative period was similar between the groups . There was a significant reduction in the measures of diaphragmatic excursion in both the groups . CONCLUSION : The preoperative inspiratory muscle training increased the inspiratory muscle strength ( maximal inspiratory pressure ) and attenuated the negative postoperative effects of open bariatric surgery in obese women for this variable , though not influencing the lung volumes and the diaphragmatic excursion The object of the investigation was to compare the effect of three different physiotherapy masks on the incidence of postoperative complications after thoracic surgery . It was carried out as a prospect i ve , consecutive , r and omized comparison at a Department of Thoracic and Heart Surgery at a University Hospital . The therapy was performed by experienced and specially trained physiotherapists . One hundred and sixty patients were evaluated ; 60 patients undergoing heart surgery , 59 patients having pulmonary resection , and 41 patients with exploratory thoracotomy . In each operative category the patients were treated with one of three face mask systems used in addition to routine chest physiotherapy . These were either continuous positive airway pressure ( CPAP ) , positive expiratory pressure ( PEP ) , or inspiratory resistance -- positive expiratory pressure ( IR-PEP ) . Postoperative pulmonary complications were assessed by forced vital capacity ( FVC ) , arterial oxygen tension ( PaO2 ) , and chest X-ray examination , all parameters were measured preoperatively and on the fourth and ninth postoperative day . The patients filled in a question naire concerning their opinions about their mask treatment . IR-PEP showed a lesser decrease in PaO2 on day nine . Otherwise there was an equal decrease in FVC and PaO2 , and equal frequency of atelectasis in the three mask treatments . It is therefore concluded that any of the three therapies : continuous positive airway pressure ( CPAP ) , positive expiratory pressure ( PEP ) , and inspiratory resistance -- positive expiratory pressure ( IR-PEP ) may be used as supplement to st and ard chest physiotherapy A prospect i ve r and omized controlled trial was conducted in patients undergoing elective cholecystectomy  to assess the value of routine chest physiotherapy .  One hundred and two patients entered the study : 47 patients developed no pulmonary complications , 29 had pulmonary atelectasis and a further 26 developed chest infection . The pattern of changes in arterial oxygen tension in the period after operation supported the clinical allocation of the patients . Of 51 patients not receiving physiotherapy  , 11 developed atelectasis and 19 chest infection . Of 51 treated patients , 18 developed atelectasis and seven chest infection .  Routine prophylactic postoperative chest physiotherapy decreased significantly the frequency of chest infection ( P less than 0.02 ) PURPOSE To determine the relation between cardiac and noncardiac complications and their effects on length of stay in patients undergoing noncardiac surgery . METHODS We collected detailed information from the history , physical examination , and preoperative tests of 3970 patients aged > or = 50 years who were undergoing major noncardiac procedures . Serial electrocardiograms and cardiac enzyme measurements were performed perioperatively , and cardiac and noncardiac complications were recorded prospect ively . Multivariate logistic regression analysis was used to determine the association between cardiac and noncardiac complications , and linear regression was used to assess their effects on length of stay . RESULTS Cardiac complications occurred in 84 patients ( 2 % ) , and noncardiac complications developed in 510 patients ( 13 % ) . Both types of complications occurred in 40 patients ( 1 % ) . The most common cardiac complications were pulmonary edema ( n = 42 ) and myocardial infa rct ion ( n = 41 ) . The most common noncardiac complications were wound infection ( n = 291 ) , confusion ( n = 87 ) , respiratory failure requiring intubation ( n = 62 ) , deep venous thrombosis ( n = 48 ) , and bacterial pneumonia ( n = 46 ) . Patients with cardiac complications were more likely to suffer a noncardiac complication than were those without cardiac complications , even after adjustment for preoperative clinical factors ( odds ratio = 6.4 ; 95 % confidence interval [ CI ] : 3.9 to 10.6 ) . Mean length of stay was markedly increased in patients who experienced cardiac ( 11 days ; 95 % CI : 9 to 12 days ) or noncardiac ( 11 days ; 95 % CI : 10 to 12 days ) complications , or both ( 15 days ; 95 % CI : 12 to 18 days ) , as compared with patients without complications ( 4 days ; 95 % CI : 3 to 4 days ) , even after adjustment for procedure type and clinical factors . CONCLUSION Cardiac and noncardiac complications were strongly linked in patients undergoing noncardiac surgery . Patients who experienced one type of complication were at increased risk of developing the other type of complication as well as prolonged perioperative length of stay Forty-nine adults who had undergone cardiopulmonary bypass surgery were r and omly assigned to one of three exercise programs to determine if either maximal inspiratory breathing exercises or incentive spirometry offered a therapeutic advantage over early mobilization alone . After extubation , the patients started their assigned exercise programs . A physical examination and pulmonary function tests were performed preoperatively , at the start of the exercise program , and 24 and 48 hours after the start of the program . The results showed a significant decrease ( approximately 50 % ) in lung volumes but no airflow obstruction in patients who had coronary artery bypass graft . In those patients who had valve replacement , lung volumes fell , and in addition , mild airflow obstruction occurred . A majority of patients had postoperative pulmonary complications . There were no significant differences among the exercise programs in improving lung volumes and airflow or in preventing postoperative complications . We conclude that maximal inspiratory breathing exercises or incentive spirometry , when used in addition to early mobilization , offers no therapeutic advantage over early mobilization alone after cardiopulmonary bypass surgery Blow-bottles were compared with conventional postoperative pulmonary physiotherapy  in a r and omized trial of 98 patients undergoing gastric or biliary tract surgery . Radiological evidence of postoperative pulmonary lesions found by " blind " evaluation of the films occurred with the same frequency in the two groups ( 30.6 % ) . Blow-bottles were found preferable to physiotherapy because they are less time-consuming Objective : To determine in a pilot study the feasibility and effects of preoperative inspiratory muscle training in patients at high risk of postoperative pulmonary complications who were scheduled for coronary artery bypass graft surgery . Design : Single-blind , r and omized controlled pilot study . Setting : University Medical Centre Utrecht , the Netherl and s. Subjects : Twenty-six patients at high risk of postoperative pulmonary complications were selected . Intervention : The intervention group ( N = 14 ) received 2 - 4 weeks of preoperative inspiratory muscle training on top of the usual care received by the patients in the control group . Main measures : Primary outcome variables of feasibility were the occurrence of adverse events , and patient satisfaction and motivation . Secondary outcome variables were postoperative pulmonary complications and length of hospital stay . Results : The feasibility of inspiratory muscle training was good and no adverse events were observed . Treatment satisfaction and motivation , scored on 10-point scales , were 7.9 ( ± 0.7 ) and 8.2 ( ± 1.0 ) , respectively . Postoperative atelectasis occurred in significantly fewer patients in the intervention group than in the control group ( ϰ2 DF1 = 3.85 ; P = 0.05 ) : Length of hospital stay was 7.93 ( ± 1.94 ) days in the intervention group and 9.92 ( ± 5.78 ) days in the control group ( P = 0.24 ) . Conclusion : Inspiratory muscle training for 2 - 4 weeks before coronary artery bypass graft surgery was well tolerated by patients at risk of postoperative pulmonary complications and prevented the occurrence of atelectasis in these patients . A larger r and omized clinical trial is warranted In Ontario , Canada , the discrepancy between the high dem and for  coronary artery bypass graft surgery ( CABG )  and the low immediate supply results in waiting lists . In 1990 , a consensus panel of cardiologists and surgeons developed criteria to ensure that high-risk patients were given priority for this procedure ( 1 ) . Each patient receives an acuity score that corresponds to a recommended maximum delay . Aggregated acuity scores of 4 , 5 , 6 , and 7 indicate elective status and represent a waiting time ranging from greater than 14 days to a maximum of 6 months . The mortality rate for patients awaiting CABG  has been shown to be remarkably stableapproximately 0.5 % to 0.6 % per year over the past 10 years ( 2 ) . Despite this , however , evidence shows that patients ' functional and psychological status can deteriorate during the wait for surgery ( 3 - 5 ) . Through its effects on the autonomic nervous system , emotional stress also influences catecholamines , myocardial oxygen dem and , and platelet aggregation ; this may affect morbidity during the waiting period ( 6 - 8 ) . Such factors as preoperative anxiety and little social support have adverse psychological effects during extended preoperative waiting periods and , in addition , have been found to predict poor physical recovery from heart surgery ( 9 ) . Therefore , psychological factors and physical deconditioning , both of which occur during the waiting period ( 10 - 12 ) , may negatively affect patients ' in-hospital course , including length of stay . Because waiting for health services will probably continue to be a reality in publicly funded health care systems that value universal access , careful study of simple , affordable methods to improve patient outcomes during the waiting period is warranted . We examined the effect of a minimum 8-week , multidimensional , preoperative intervention on the presurgery and postsurgery outcomes of patients awaiting elective CABG . We hypothesized that a combination of exercise training , education , and social support would affect patients ' physical and psychological readiness for surgery and thereby reduce postoperative length of hospital stay . We further hypothesized that the effectiveness of the preoperative intervention would be sustained into the first 6 months of the postoperative period . Methods Patients Patients were recruited from the waiting lists of all seven cardiovascular surgeons operating in the Hamilton Health Sciences Corporation surgical center , Hamilton , Ontario , Canada . Each year , approximately 1300 open-heart surgeries are performed in this center . Roughly 60 % of patients awaiting CABG have elective status and are placed on the waiting list . During the time of our study , elective waiting times ranged from 3 weeks to greater than 20 weeks . Approximately 40 % of elective patients are usually awaiting first-time  CABG ( nonvalve replacement ) . Only patients awaiting a first CABG whose surgery date s were at least 10 weeks away were approached to participate in our study . Patients were excluded if they were having combined CABG and valve surgery , if their ejection fractions were less than 0.40 , if they could not attend the exercise classes because of geographic inaccessibility , or if they were unable to participate because of physical limitations . After these inclusion and exclusion criteria were applied , our pool of potential participants was approximately 250 patients per year . We intended to select low-risk patients because it is not common to test an exercise intervention in patients awaiting CABG . Design We design ed a two-group r and omized , controlled trial . Eligible patients were r and omly assigned to 8 weeks of multidimensional preoperative intervention or to usual care . Those assigned to usual care were followed by their primary care physicians , cardiologists , or surgeons . During the waiting period , the intervention group received individualized , prescribed exercise training twice per week in a supervised environment ; education and reinforcement ; and monthly nurse-initiated telephone calls to answer questions and provide reassurance . After surgery , patients in both the treatment and control groups were given the opportunity to join the existing cardiac rehabilitation program ( Appendix ) . Outcomes The primary outcome was postoperative length of hospital stay . Secondary outcomes were peak exercise performance , health-related quality of life , social support , anxiety , and utilization of health care services . Measurements were taken at baseline , 1 week before surgery , 6 to 8 weeks after surgery , and 6 months after surgery . All of the secondary outcome variables were measured at baseline and 1 week before surgery . At 6 weeks and 6 months after surgery , only exercise performance , quality of life , and social support were measured . Determination of Sample Size Sample size was determined by using 19941995 data on length of stay in our surgical center . According to a r and om sample of 20 patients undergoing elective CABG , the mean total length of stay SD was 9.4 3.5 days . On the basis of these data , and accounting for a loss of 10 % to 15 % of patients , we determined that a sample size of 125 patients per group had sufficient power ( 0.8 ) to detect a 1-day reduction in hospital stay ( = 0.05 ) . Procedures The Research Ethics Board of McMaster University ( Hamilton , Ontario ) and the study hospital approved the study . On a weekly basis , staff at each of the surgeon 's offices supplied the names of patients who were scheduled to wait at least 10 weeks for surgery . Patients were telephoned , and the study was explained to them . The recruitment officer was completely c and i d about the r and om assignment and the treatments that would be offered to each group . Within 1 week after giving verbal consent , patients came to the clinic to provide written informed consent . At this visit , we collected complete baseline data and patients underwent an exercise test . Baseline data included demographic information ( age , sex , socioeconomic status , living arrangements , education , and employment status ) ; medical history ; past and present smoking status ; and history of myocardial infa rct ion , angina , congestive heart failure , and diabetes . Baseline data were also collected on anxiety , health-related quality of life , utilization of health care services , and social support . Data later obtained from medical records included total length of hospital stay , length of postoperative stay , number of hours spent in the intensive care unit ( ICU ) before receiving a discharge order , and actual hours spent in the ICU . R and omization and Blinding The study coordinator r and omly assigned patients to study groups by using a concealed r and omization process . A consultant prepared the r and omization schedule , and assignments were sealed in opaque envelopes that were opened in sequence after consent and baseline data were obtained . Patients were not blinded to their group assignments . However , the patients ' physicians ( cardiologists , surgeons , and general practitioners ) were blinded to group assignment and were not informed of it at any point in the study by patients or health care staff . Persons involved in offering the intervention ( nurses , kinesiologists , dietitians ) were aware of the patients ' group assignments but had no role in determining the patients ' readiness for discharge from the ICU or from the hospital ; therefore , they did not directly affect the primary outcome . Assessment of Outcomes Data on length of stay were collected by individual chart review . Total length of stay and total length of ICU stay were easily determined by using admission and discharge date s. However , after discussion with the cardiovascular surgeons before the study began , we realized that total length of ICU stay would misrepresent patients ' postoperative progress . On many occasions , the patient is ready for discharge from the ICU but bed or staffing issues substantially delay his or her actual departure . Therefore , we collected data on length of ICU stay in hours and , more particularly , in hours until order for ICU discharge . This required detailed chart review to locate time in and time out information as well as the time that the physician 's discharge order was given . Although the physicians often did not record the times of their orders , these data were found in nurses ' ICU notes . In approximately 5 % of cases , the data were not retrievable and the mean time until order for discharge was imputed . Exercise performance was measured by using a symptom-limited , upright-cycle ergometer exercise test .  General health-related quality of life was measured by using the Medical Outcomes Study 36-item Short Form Survey ( SF-36 ) ( 13 ) .  Social support was measured by using the  Interpersonal Support Evaluation List  ( 14 ) , and the total scale score was used in analysis . Anxiety was measured with the Spielberger StateTrait Anxiety Inventory ( 15 ) , from which both a trait score and a state anxiety score were computed . The total score from the Health Services Utilization Question naire ( 16 ) was computed and used in the analysis ( Appendix ) . Statistical Analysis All analyses were performed by using the SPSS statistical package ( 17 ) , versions 6.0 and 8.0 ( SPSS , Inc. , Chicago , Illinois ) . We analyzed data on patients whose status was elective from study entry until 1 week before surgery ( n = 220 ) . Data were complete for the primary outcome variables . When a measurement tool did not supply an approach for dealing with missing data , we used an imputation strategy , the hot deck approach ( 18 ) , in which the score from a matched patient in the same group is substituted for the missing score . The defining characteristics for matching patients were age , sex , and number of bypasses required . At the measurement point 6 months after surgery , 78 % of patients returned for all final assessment s. Follow-up to establish vital status was complete for all patients . Data on length of stay are usually positively skewed . Therefore , we selected the MannWhitney test for Objective An investigation into the incidence of post-operative complications after thoracic surgery with  3 different physiotherapy masks . Design A prospect i ve , consecutive , r and omized comparison . Setting Department of Thoracic and Heart Surgery at a University Hospital . The treatments were performed by experienced and specially trained physiotherapists . Patients 160 patients were evaluated . 60 patients undergoing heart surgery , 59 patients having pulmonary resection , and 41 patients with exploratory thoractomy . Interventions In each operative category the patients were treated with one of three face mask systems used in addition to routine chest physiotherapy . These were either continuous positive airway pressure ( CPAP ) , positive expiratory pressure ( PEP ) , or inspiratory resistance — positive expiratory pressure ( IR-PEP ) . Measurements and results Post-operative pulmonary complications were assessed by forced vital capacity ( FVC ) , arterial oxygen tension ( PaO2 ) , and chest X-ray examination , all measured pre-operatively and on the fourth and ninth post-operative day . The patients filled in a question naire expressing their opinion about their mask treatment . There was an equal decrease in FVC , FVC% , and PaO2 , and equal frequency of atelectasis in the 3 mask treatments . More patients with the PEP mask favoured their system than did those with the other 2 systems . Conclusion There was no statistically significant difference between the treatments : continuous positive airway pressure ( CPAP ) , positive expiratory pressure ( PEP ) , and inspiratory resistance — positive expiratory pressure ( IR-PEP ) on post-operative complications . Any of the three treatments may be used as supplement to st and ard chest physiotherapy BACKGROUND Respiratory muscles are affected after cardiac surgeries . OBJECTIVE To verify whether the preoperative conditioning of the inspiratory muscles might help to decrease postoperative respiratory dysfunction . METHODS Thirty volunteers of both genders and with a minimum age of 50 years , while waiting for myocardial revascularization and /or cardiac valve surgery , were r and omly assigned to two groups . Fifteen patients were included in a domiciliary program of at least 2 weeks of preoperative training of the inspiratory muscles , using a device with a load corresponding to 40 % of the maximum inspiratory pressure . The other 15 patients received general advice and did not train the inspiratory muscle . Spirometry  , before and after the training program , as well as the evolution of the arterial blood gases and of the maximum inspiratory and expiratory pressure , before and after the operation were evaluated in both group . The clinical outcomes of the two groups were also compared . RESULTS We observed that inspiratory muscle training  increased the forced vital capacity , the maximum voluntary ventilation and the ratio between the forced expired volume during the first second and the forced vital capacity . The evolution of the arterial blood gases and of the maximum inspiratory and expiratory pressures before and after the operation was similar in both groups , with the outcomes also being similar . CONCLUSION We concluded that our domiciliary program of inspiratory muscle training was safe and improved the forced vital capacity and the maximum voluntary ventilation , although the clinical benefits of this program were not clearly demonstrable in the present study One hundred and ten men undergoing coronary artery bypass grafting took part in a prospect i ve r and omised study comparing three physiotherapy protocol s. All patients were taught self supported huffing and coughing by a physiotherapist and encouraged to move about . This comprised the sole treatment for the 37 control patients ( group 3 ) . Additional physiotherapy included breathing exercises for the 35 patients in group 1 and use of an incentive spirometer for the 38 patients in group 2 . Functional residual capacity ( FRC ) was measured daily at the bedside until the fifth postoperative day and arterial blood gas tensions were measured on the second and fourth postoperative days . After surgery patients developed a severe restrictive ventilatory defect and profound arterial hypoxaemia . There were no differences between the three groups . Mean FRC on day 2 was 1.90 litres ( 61 % of the preoperative value ) , increasing to 2.32 1 by day 5 ( 76 % of the preoperative value ) . The mean arterial oxygen tension was 7.37 kPa on day 2 and 8.58 kPa on day 4 . Four patients in group 1 , two in group 2 , and five in group 3 developed a chest infection . It is concluded that the addition of breathing exercises or incentive spirometry to a regimen of early mobilisation and huffing and coughing confers no extra benefit after uncomplicated coronary artery bypass grafting Pulmonary complications are frequently seen after thoracoabdominal resection of the oesophagus . The aim of this study was to compare the effects of two different breathing exercise regimens applied in the immediate postoperative period on the risk of pulmonary insufficiency after thoracoabdominal resection The effect of three postoperative regimes of respiratory therapy on  pulmonary complications and lung function was compared in high‐risk patients . Fifty‐one patients were r and omized to : 1 ) conventional chest physiotherapy alone ( PHYS ) , 2 ) chest physiotherapy and positive expiratory pressure ( PEP ) , or 3 ) chest physiotherapy with both positive expiratory pressure and inspiratory resistance ( RMT ) . Treatments were given twice daily by a physiotherapist and self‐administered . The incidence of postoperative pulmonary complications ( PPC ) was respectively , 71 % , 76 % and 65 % in the PHYS‐ , PEP‐ and RMT‐groups . The incidence of PPC requiring treatment with antibiotic , bronchodilator or supplementary oxygen according to the existing clinical practice was 47 % , 47 % and 29 % . The incidence of atelectasis was 65 % , 64 % and 60 % and of pneumonia 29 % , 35 % and 6 % . There was no difference between the groups , except for a tendency to a lower frequency of pneumonia in the RMT‐group . Postoperatively forced vital capacity ( FVC ) decreased to mean 54 % , forced expired volume in 1 s to 48 % and functional residual capacity to 76 % of preoperative values . Arterial oxygen tension ( Pao2 ) declined to mean 8.1 kPa and arterial saturation ( Sao2 ) to 89 % . There was no difference between the groups except for FVC , Pao2 and Sao2 ( P = 0.008 , P = 0.008 and P = 0.002 ) , which showed the least decrease in the RMT‐group . None of the regimens could be considered as satisfactory concerning the prevention of PPC , but RMT seemed to be the most efficient . Insufficient self‐administration of treatment was probably one of the causes of the overall high incidence of PPC in this study Abstract Objective . To investigate the efficiency of inspiratory muscle training ( IMT ) on postoperative respiratory muscle strength , functional capacity , quality of life , and psychosocial status in patients with coronary artery bypass graft ( CABG ) surgery . Design . Forty-three patients undergoing CABG surgery were r and omly assigned to the one of two groups . All subjects received usual care . In addition , subjects in the intervention group received IMT training pre- and postoperatively . Pulmonary function testing , six minute walk test ( 6MWT ) , quality of life and psychosocial parameters were assessed preoperatively and the fifth day after the surgery . Results . The mean inspiratory muscle strength increased from 82.64 cmH2O at baseline to 95.45 cmH2O five days postoperatively in the intervention group . The intervention group ( 319.55 ± 72.17 m before and 387.91 ± 65.69 m after surgery ) covered further distance during the 6MWT than usual care ( 355.43 ± 56.08 m before and 357.69 ± 43.42 m after surgery ) . The improvement in quality of life was greater in the intervention group for the dimension of sleep . The anxiety scores were significantly lower in the intervention group than the usual care group . The length of intensive care unit stay was significantly shorter in the intervention group than the usual care group ( p < 0.05 ) . Conclusion . IMT results in faster recovery of inspiratory muscle strength , functional capacity , intensive care unit stay , quality of life and psychosocial status after CABG OBJECTIVES 1 ) To demonstrate the impaired ventilatory capacity during the post operatory period , in patients su bmi tted to coronary arterial bypass graft surgery ( CABG ) . 2 ) To test the hypothesis that the respiratory muscle training ( RMT ) , performed after the surgery , may increase the ventilatory capacity in this population . METHODS Thirty-eight patients ( age : 65 ± 7 years , 29 male ) , whose underwent CABG with extra-corporeal circulation . Patients were r and omized in two groups : 23 patients in the RMT group and 15 in the control group ( CO ) . RMT group received conventional physiotherapy plus RMT . The CO group received the conventional physiotherapy . Evaluated parameters : maximum inspiratory and expiratory pressures ( MIP ) ( MEP ) , dyspnea ( Borg ) , peak expiratory flow ( PEF ) , pain , tidal volume and hospitalization days . Measures were performed at pre , first post operatory day and also at the patients discharge from the hospital ) . RESULTS MIP and MEP in the RMT group were higher when compared with CO at the patients discharge ( MIP : 90 ± 26 vs. 55 ± 38 cmH2O , P = 0.01 ) ( MEP : 99 ± 30 vs. 53 ± 26 cmH2O , P = 0.02 ) . The PEF was higher after hospitalization in the RMT group ( 237 ± 93 vs. 157 ± 102 lpm , P=0.02 ) . Tidal volume was also higher in the RMT group at discharge ( 0.71 ± 0.21 vs. 0.44 ± 0.12 liters , P = 0,00 ) . No differences were observed among the groups in the aspects : admission days , dyspnea and pain . CONCLUSIONS Patients su bmi tted to CABG presents an impaired respiratory muscle strength in their post operatory . RMT performed in this phase was effective to restore the ventilatory capacity in the following parameters : MIP , MEP , PEF and tidal volume , in this group of patients Objective : To investigate the feasibility and effects of preoperative inspiratory muscle training on the incidence of atelectasis in patients at high risk of postoperative pulmonary complications scheduled for elective abdominal aortic aneurysm surgery . Design : Single-blind r and omized controlled pilot study . Setting : Gelderse Vallei Hospital Ede , the Netherl and s. Subjects : Twenty high-risk patients undergoing elective abdominal aortic aneurysm surgery were r and omly assigned to receive preoperative inspiratory muscle training or usual care . Main measures : Effectiveness outcome variables were atelectasis , inspiratory muscle strength and vital capacity , and feasibility outcome variables were adverse effects and patient satisfaction with inspiratory muscle training . Results : Despite r and omization , patients in the intervention group were significantly older than the patients in the control group ( 70 ± 6 years versus 59 ± 6 years , respectively ; P = 0.001 ) . Eight patients in the control group and three in the intervention group developed atelectasis ( P = 0.07 ) . The median duration of atelectasis was 0 days in the intervention group and 1.5 days in the control group ( P = 0.07 ) . No adverse effects of preoperative inspiratory muscle training were observed and patients considered that inspiratory muscle training was a good preparation for surgery . Mean postoperative inspiratory pressure was 10 % higher in the intervention group . Conclusion : Preoperative inspiratory muscle training is well tolerated and appreciated and seems to reduce the incidence of atelectasis in patients scheduled for elective abdominal aortic aneurysm surgery Objective : This study examined whether involvement in a  pre-surgical cardiac rehabilitation programme  conferred a long-term survival benefit . Design : Patients r and omly allocated to a pre-surgical cardiac rehabilitation programme intervention or a control group  were tracked through national data bases at a point approximately 12 years later , and all causes of mortality were identified from death records . Kaplan – Meier survival analyses based on involvement in a cardiac rehabilitation programme and known pre-surgical risk factors were carried out . Setting : Two health boards in the west of Scotl and , referring to a single cardiothoracic tertiary centre . Subjects : Patients admitted to the waiting list for coronary artery bypass surgery . Interventions : Patients were r and omly allocated to a control group ( ‘ usual ’ care ) or an intervention group ( nurse-led cardiac rehabilitation ) in the pre-operative phase . They were followed up at 12 years post surgery . Main measures : The only outcome measure used for analysis was survival . Measures of anxiety and depression , and physiological and lifestyle risk factors were included as independent variables in analysis of death . Results : The initial study included 110 patients – none were lost to follow-up . Relative risk of death associated with inclusion in the cardiac rehabilitation programme was 0.814 ; risk of death increased with increasing pre-surgical depression ( RR 1.07 ) and anxiety ( RR 1.09 ) . Conclusions : Undertaking pre-surgical cardiac rehabilitation confers a long-term survival advantage over patients not offered this service . Increased anxiety and depression in the pre-surgical phase are additional risk factors for increased mortality The objective of this prospect i ve , consecutive , r and omized , controlled study was to investigate the effects of mask physiotherapy on postoperative complications after heart surgery . Sixty-six low-risk male patients undergoing coronary artery by-pass graft surgery were evaluated . The patients were treated with routine chest physiotherapy alone or supplied with either positive expiratory pressure ( PEP ) , or inspiratory resistance-positive expiratory pressure ( IR-PEP ) . Postoperative pulmonary complications were assessed by forced vital capacity ( FVC ) , arterial oxygen tension ( PaO2 ) , and chest X-ray examination . There was an almost equal decrease and subsequent rise in spirometric and blood gas values in all three groups , but patients treated with the PEP mask had a borderline significantly higher increase in PaO2 from day three to day six compared with patients treated with no mask . There was an almost equal frequency of atelectasis in the three treatment groups . It is concluded that no significant differences in outcome were found between the three groups Objective Investigate the effects of mask physiotherapy on post-operative complications after thoracic surgery . Design A prospect i ve , consecutive , r and omized , controlled study . Setting Department of Thoracic and Heart Surgery at a University Hospital . The treatments were performed by experienced and specially trained physiotherapists . Patients 97 low-risk male patients undergoing coronary artery by-pass graft surgery were evaluated . 66 patients completed the study . Interventions The patients were treated with routine chest physiotherapy alone or supplied with either positive expiratory pressure ( PEP ) , or inspiratory resistance-positive expiratory pressure ( IR-PEP ) . Measurements and results Post-operative pulmonary complications were assessed by forced vital capacity ( FVC ) , arterial oxygen tension ( PaO2 ) , and chest X-ray examination , all measured pre-operatively and on the third and sixth post-operative day . There was an almost equal decrease and subsequent rise in spirometric and blood gas values , but patients treated with the PEP mask had a borderly significantly higher increase in PaO2 from day 3 to day 6 compared with patients treated with no mask . There was an almost equal frequency of atelectasis in the 3 treatments . The patients filled in a question aire expressing their opinion about their treatment . Most patients liked their treatment and found it helpful but a little less so in the IR-PEP group . Conclusion We did not find any significant difference between the three groups ; however , a tendency to decreased risk of having post-operative complications was observed in the groups having positive expiratory pressure ( PEP ) and inspiratory resistance-positive expiratory pressure ( IR-PEP ) Introduction This r and omized controlled study evaluated the clinical benefit and physiological effects of prophylactic chest physiotherapy in open major abdominal surgery Background This study seeks to assess the effect of inspiratory muscle training ( IMT ) on pulmonary function , respiratory muscle strength , and endurance in morbidly obese patients su bmi tted to bariatric surgery . Methods Thirty patients were r and omly assigned to sham muscular training , or to IMT with a threshold device ( 40 % of maximum inspiratory pressure , MIP ) , for 30 min/day , from the 2nd until 30th postoperative ( PO ) day . All of them were su bmi tted to a st and ard respiratory kinesiotherapy and early deambulation protocol . Data on spirometry , maximum static respiratory pressures , and respiratory muscle endurance were collected on the PO days 2 , 7 , 14 , and 30 in a blinded matter . Results IMT enabled increases in PO MIP and endurance , and an earlier recovery of the spirometry parameters FEV1 , PEF , and FEF25–75 % . Comparing to preoperative values , MIP was increased by 13 % at the 30th PO day in the trained group , whereas control group had a reduction of 8 % , with higher values for the IMT group ( 30th PO , IMT—130.6 ± 22.9 cmH2O ; controls—112.9 ± 25.1 cmH2O ; p < 0.05 ) . Muscular endurance at the 30th PO day was increased in the trained group comparing to preoperative value ( 61.5 ± 39.6 s vs 114.9 ± 55.2 s ; p < 0.05 ) , a finding not observed in the control group ( 81.7 ± 44.3 vs 95.2 ± 42.0 s ) . Conclusions IMT improves inspiratory muscle strength and endurance and accounts for an earlier recovery of pulmonary airflows in morbidly obese patients su bmi tted to bariatric surgery CONTEXT Most medical interventions have modest effects , but occasionally some clinical trials may find very large effects for benefits or harms . OBJECTIVE To evaluate the frequency and features of very large effects in medicine . DATA SOURCES Cochrane Data base of Systematic Review s ( CDSR , 2010 , issue 7 ) . STUDY SELECTION We separated all binary- outcome CDSR forest plots with comparisons of interventions according to whether the first published trial , a subsequent trial ( not the first ) , or no trial had a nominally statistically significant ( P < .05 ) very large effect ( odds ratio [ OR ] , ≥5 ) . We also sample d r and omly 250 topics from each group for further in-depth evaluation . DATA EXTRACTION We assessed the types of treatments and outcomes in trials with very large effects , examined how often large-effect trials were followed up by other trials on the same topic , and how these effects compared against the effects of the respective meta-analyses . RESULTS Among 85,002 forest plots ( from 3082 review s ) , 8239 ( 9.7 % ) had a significant very large effect in the first published trial , 5158 ( 6.1 % ) only after the first published trial , and 71,605 ( 84.2 % ) had no trials with significant very large effects . Nominally significant very large effects typically appeared in small trials with median number of events : 18 in first trials and 15 in subsequent trials . Topics with very large effects were less likely than other topics to address mortality ( 3.6 % in first trials , 3.2 % in subsequent trials , and 11.6 % in no trials with significant very large effects ) and were more likely to address laboratory-defined efficacy ( 10 % in first trials,10.8 % in subsequent , and 3.2 % in no trials with significant very large effects ) . First trials with very large effects were as likely as trials with no very large effects to have subsequent published trials . Ninety percent and 98 % of the very large effects observed in first and subsequently published trials , respectively , became smaller in meta-analyses that included other trials ; the median odds ratio decreased from 11.88 to 4.20 for first trials , and from 10.02 to 2.60 for subsequent trials . For 46 of the 500 selected topics ( 9.2 % ; first and subsequent trials ) with a very large-effect trial , the meta- analysis maintained very large effects with P < .001 when additional trials were included , but none pertained to mortality-related outcomes . Across the whole CDSR , there was only 1 intervention with large beneficial effects on mortality , P < .001 , and no major concerns about the quality of the evidence ( for a trial on extracorporeal oxygenation for severe respiratory failure in newborns ) . CONCLUSIONS Most large treatment effects emerge from small studies , and when additional trials are performed , the effect sizes become typically much smaller . Well-vali date d large effects are uncommon and pertain to nonfatal outcomes Herdy AH , Marcchi PLB , Vila A , Tavares C , Collaço J , Niebauer J , Ribeiro JP : Pre- and postoperative cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery bypass surgery : a r and omized controlled trial . Am J Phys Med Rehabil 2008;87:714–719 . Objective : Patients who have to wait in the hospital for coronary artery bypass surgery ( CABG ) are exposed to the potential risks of immobilization . This clinical trial was conducted to evaluate the effects of an in-hospital cardiopulmonary rehabilitation program performed before and after CABG on postoperative outcomes . Design : Fifty-six patients who had to wait for CABG in-hospital were r and omly assigned to a cardiopulmonary rehabilitation ( Rehab ; n = 29 ) or to usual care ( Control ; n = 27 ) . In the Rehab group , intervention lasted for at least 5 days preoperatively until discharge . The program consisted of phase I cardiac rehabilitation associated with respiratory physical therapy . Outcomes were blindly evaluated . Results : By hospital discharge , Rehab patients presented a shorter time to endotracheal extubation ( 1054 ± 376 vs. 1340 ± 666 min , P = 0.05 ) , a reduction in the incidence of pleural effusion ( relative risk [ RR ] = 0.2 ; 95 % confidence interval [ CI ] : 0.5–0.8 ) , atelectasis ( RR = 0.15 ; 95 % CI : 0.03–0.8 ) , pneumonia ( 0 vs. 7 cases , [ P = 0.004 ] ) , and atrial fibrillation or flutter ( RR = 0.2 ; 95 % CI : 0.05–0.8 ) . Length of in-hospital stay after surgery was also reduced in the Rehab group ( 5.9 ± 1.1 vs. 10.3 ± 4.6 days [ P < 0.001 ] ) . Conclusion : Pre- and postoperative cardiopulmonary rehabilitation in patients who await CABG in the hospital is superior to st and ard care and leads to a reduced rate of postoperative complications and shorter hospital stay OBJECTIVE The aim of this study was to evaluate the prophylactic efficacy of preoperative physiotherapy , including inspiratory muscle training ( IMT ) , on the incidence of postoperative pulmonary complications ( PPCs ) in high-risk patients scheduled for elective coronary artery bypass grafting ( CABG ) . DESIGN R and omized controlled clinical trial ( www.controlled-trials . com/is rct n17691887 ) . METHOD Of 655 patients referred to a university medical centre in The Netherl and s for elective CABG , 299 met the criteria for being at high risk of developing PPCs . A total of 279 were enrolled and monitored up to discharge from hospital . Patients were r and omly assigned to receive either preoperative IMT ( n=140 ) or usual care ( n=139 ) . Both groups received the same postoperative treatment . RESULTS Both groups were comparable at baseline . Before CABG , 2 control group patients and 1 IMT group patient died . After CABG surgery , PPCs were present in 25 ( 18 % ) of 139 patients in the IMT group and 48 ( 35 % ) of 137 patients in the control group ( OR : 0.52 ; 95 % CI : 0.30 - 0.92 ) . Pneumonia occurred in 9 ( 6.5 % ) of 139 patients in the IMT group and in 22 ( 16.1 % ) of 137 patients in the usual care group ( OR : 0.40 ; 95 % CI : 0.19 - 0.84 ) . Mean duration of postoperative hospitalization was 7 ( range 5 - 41 ) days in the IMT group versus 8 ( range 6 - 70 ) days in the usual care group ( Mann-Whitney test ; Z : -2.42 ; p = 0.015 ) . CONCLUSION Preoperative physiotherapy , including IMT , statistically significantly reduced the incidence ofPPCs and the duration ofpostoperative hospitalization in patients at high risk of developing a pulmonary complication on undergoing CABG Controversy exists regarding the routine use of aids to lung expansion in the prevention of pulmonary complications after abdominal surgery . We prospect ively r and omized 172 patients into 1 of 4 groups : the  control group ( 44 patients ) received no respiratory treatment  , the IPPB  group ( 45 patients ) received intermittent positive pressure breathing therapy for 15 min 4 times daily , the IS group ( 42 patients ) was treated with incentive spirometry 4 times daily , and the DBE group ( 41 patients ) carried out deep breathing exercises under supervision for 15 min 4 times daily . Roentgenographic changes , observed 24 h after surgery , were comparable in the 4 groups ( 20.5 to 36.6 % ) . Pulmonary complications were defined as the development of 3 or more of 6 new findings : cough , phlegm , dyspnea , chest pain , temperature greater than 38 degrees C , pulse rate more than 100 beats/min . The frequency of development of pulmonary complications was 48 % in the control group , 22 % in the IPPB group ( p less than 0.05 ) , 21 % in the IS group ( p less than 0.05 ) , and 22 % in the DBE group ( p less than 0.05 ) . Side effects of respiratory treatment were observed only in the IPPB group ( 18 % ; p less than 0.05 ) . Hospital stay in patients undergoing upper abdominal surgery was significantly shorter in the IS group ( mean + /- SD , 8.6 + /- 3 days ) than in the control group ( 13 + /- 5 days ) . This difference was not observed for the other 2 treatment groups . ( ABSTRACT TRUNCATED AT 250 WORDS STUDY OBJECTIVE To determine whether higher personnel intensive chest physical therapy can prevent the atelectasis that routinely follows cardiac valve surgery . DESIGN R and omized , controlled trial . SETTING Tertiary care hospital . PATIENTS Seventy-eight patients undergoing elective cardiac valve surgery between October 1991 and April 1993 were enrolled . INTERVENTIONS Patients were r and omized in an unmasked fashion to receive early mobilization and sustained maximal inflations ( lower-intensity treatment ) or to receive early mobilization , sustained maximal inflations , and single-h and ed percussions ( higher-intensity treatment . ) MEASUREMENTS AND RESULTS Clinical efficacy was determined by extent of atelectasis , length of ICU stay , total length of hospital stay , and personnel costs . The extent of postoperative atelectasis was similar in both groups on the fifth postoperative day . Postoperative values of FVC and FEV1 were reduced to a similar extent in both groups . Hospital stays and ICU stays were similar regardless of treatment . Physical therapy costs were highest in the higher-intensity therapy group . CONCLUSIONS Postoperative respiratory dysfunction is common but does not usually cause significant morbidity or prolong hospital stay . The routine prescription of high-intensity physical therapy does not improve patient outcomes but does add significantly to patient costs INTRODUCTION The aim of this pilot study was to assess the effect of pre-operative inspiratory muscle training ( IMT ) on respiratory variables in patients undergoing major abdominal surgery . PATIENTS AND METHODS Respiratory muscle strength ( maximum inspiratory [ MIP ] and expiratory [ MEP ] mouth pressure ) and pulmonary functions were measured at least 2 weeks before surgery in 80 patients awaiting major abdominal surgery . Patients were then allocated r and omly to one of four groups ( Group A , control ; Group B , deep breathing exercises ; Group C , incentive spirometry ; Group D , specific IMT ) . Patients in groups B , C and D were asked to train twice daily , each session lasting 15 min , for at least 2 weeks up to the day before surgery . Outcome measurements were made immediately pre-operatively and postoperatively . RESULTS In groups A , B and C , MIP did not increase from baseline to pre-operative assessment s. In group D , MIP increased from 51.5 cmH(2)O ( median ) pre-training to 68.5 cmH(2)O ( median ) post-training pre-operatively ( P < 0.01 ) . Postoperatively , groups A , B and C showed a fall in MIP from baseline ( P < 0.01 , P < 0.01 ) and P = 0.06 , respectively ) . No such significant reduction in postoperative MIP was seen in group D ( P = 0.36 ) . CONCLUSIONS Pre-operative specific IMT improves MIP pre-operatively and preserves it postoperatively . Further studies are required to establish if this is associated with reduced pulmonary complications Pulmonary complications after cardiac surgery are a leading cause of postoperative morbidity and mortality . Respiratory muscle weakness may contribute to the postoperative pulmonary abnormalities . We hypothesized that : inspiratory muscle strength ( PImax at RV ) and endurance ( PmPeak/PImax ) decrease following  coronary artery bypass grafting ( CABG ) ; that this weakness is associated with impaired pulmonary function tests ( PFT ) , impaired gas exchange and a higher rate of pulmonary complications ; and that prophylactic inspiratory muscle training ( PIMT ) will prevent these changes . 30 c and i date s for CABG , ranging in age from 33 to 79 , were evaluated and r and omized into 2 groups : 15 received PIMT using a threshold trainer for 30 min/day for 1 month before operation , while 15 served as controls and received sham training . There was a significant decrease in respiratory muscle function , PFT , and gas exchange in the control group following CABG , while in the trained group these parameters where similar to those before entering the study . The differences between the groups were statistically significant . In addition , 4 ( 27 % ) in the control group , but only 1 ( 7 % ) in the trained group had postoperative pulmonary complications . We conclude that CABG is followed by significant deterioration in inspiratory muscle function , PFT and arterial blood gases . Decrease in these parameters can be prevented by PIMT , which may also prevent postoperative pulmonary complications Objective : Investigation of the effects of preoperative physical therapy on pulmonary function and physical performance before and after upper abdominal surgery . Design : Non-blind r and omized controlled trial . Setting : Tertiary public hospital and private university , São Paulo state , Brazil . Subjects : Thirty-two patients undergoing abdominal surgery . Interventions : Patients were r and omly assigned to receive physical therapy , with respiratory and global exercises , 2–3 weeks before surgery ( treatment group ; n = 16 ) or await operation without engaging in practicing ( control group ; n = 16 ) . After surgery , a physical therapy protocol was administered to all subjects until the seventh postoperative day . Main measures : Pulmonary function outcome variables were inspiratory and expiratory strength , respiratory muscle endurance and spirometry , and physical performance outcome variables were the functional independence measure and 6-minute walk test distance . Any postoperative pulmonary complications were recorded . Results : There were no between-group differences at r and omization . In the preoperative period , patients in the intervention group had higher inspiratory strength and respiratory muscle endurance than controls ( 88 cmH2O versus 64 cmH2O and 28 cmH2O versus 23 cmH2O , respectively ; P < 0 0.05 ) . On the seventh postoperative day , in addition to inspiratory force and respiratory muscle endurance , the intervention group showed better results than controls in the functional independence measure score ( 118 versus 95 ) and 6-minute walk test distance ( 368.5 m versus 223 m ) , all P < 0 0.05 . Postoperative pulmonary complications occurred in 11 patients in the control group and five in the intervention group ( P = 0.03 ) . Conclusion : Preoperative physical therapy improved pulmonary function and physical performance in the pre- and postoperative periods among patients undergoing upper abdominal surgery Controversy exists regarding the routine use of breathing exercises in the prevention of pulmonary complications after upper abdominal surgery . We prospect ively r and omized 153 patients who had noncompromised pulmonary status ; the control group ( 84 patients ) engaged in no breathing exercises , and the respiratory therapy group ( 69 patients ) engaged in preoperative and postoperative breathing exercises supervised by the physical therapist .  Postoperative pulmonary complications were classified using criteria derived from chest roentgenograms , arterial blood gas sample s , and temperature registration . The incidences of postoperative complications in the treatment group and in the control groups were 19 % and 60 % , respectively . In the present study , preoperative lung function tests had no additional or predictive value . We advise preoperative and postoperative breathing exercises as a prophylactic treatment in all patients scheduled for upper abdominal surgery OBJECTIVE To investigate whether the inclusion of deep breathing exercises in physiotherapy-directed early mobilisation confers any additional benefit in reducing postoperative pulmonary complications ( PPCs ) when patients are treated once daily after elective open upper abdominal surgery . This study also compared postoperative outcomes following early and delayed mobilisation . DESIGN Cluster r and omised controlled trial . SETTING Single-centre study in a teaching hospital . PARTICIPANTS Eighty-six high-risk patients undergoing elective open upper abdominal surgery . INTERVENTION Three groups : early mobilisation ( Group A ) , early mobilisation plus breathing exercises ( Group B ) , and delayed mobilisation ( mobilised from third postoperative day ) plus breathing exercises ( Group C ) . MAIN OUTCOMES PPCs and postoperative outcomes [ number of days until discharge from physiotherapy , physiotherapy input and length of stay ( LOS ) ] . RESULTS There was no significant difference in PPCs between Groups A and B. The LOS for Group A { mean 10.7 [ st and ard deviation ( SD ) 5.0 ] days } was significantly shorter than the LOS for Groups B [ mean 16.7 ( SD 9.7 ) days ] and C [ mean 15.2 ( SD 9.8 ) days ; P=0.036 ] . The greatest difference was between Groups A and B ( mean difference -5.93 , 95 % confidence interval -10.22 to -1.65 ; P=0.008 ) . Group C had fewer smokers ( 26 % ) and patients with chronic obstructive pulmonary disease ( 0 % ) compared with Group B ( 53 % and 14 % , respectively ) . This may have led to fewer PPCs in Group C , but the difference was not significant . Despite Group C having fewer PPCs and less physiotherapy input , the number of days until discharge from physiotherapy and LOS were similar to Group B. CONCLUSIONS The addition of deep breathing exercises to physiotherapy-directed early mobilisation did not further reduce PPCs compared with mobility alone . PPCs can be reduced with once-daily physiotherapy if the patients are mobilised to a moderate level of exertion . Delayed mobilisation tended to increase physiotherapy input and the number of days until discharge from physiotherapy compared with early mobilisation OBJECTIVE To investigate the efficacy of respiratory rehabilitation in preventing postoperative pulmonary complications ( PPC )  and to define which patients can benefit . DESIGN A r and omized clinical trial . SETTING A public hospital . PATIENTS Eighty-one patients who had upper abdominal surgery were distributed into two homogeneous groups : control ( n = 41 ) and rehabilitation ( n = 40 ) . INTERVENTION Breathing exercises in the rehabilitation group . MAIN OUTCOME MEASURES Preoperative and postoperative clinical evaluation , spirometry , arterial gasometry , and simple chest X-rays . RESULTS The incidence of PPC was 7.5 % in the rehabilitation group and 19.5 % in the control group ; the control group also had more radiologic alterations ( p = .01 ) . Stratified PPC analysis did not reveal significant differences between groups . However , high- and moderate-risk patients in the rehabilitation group had fewer PPC . Multivariate analysis showed a greater PPC risk associated with pulmonary history ( p = .02 ) and duration of surgery longer than 120 min ( p = .03 ) , while rehabilitation exerted a protective effect ( p = .06 ) . Significant postoperative decreases in pulmonary volumes and arterial gas values were recorded in both groups , without significant differences . CONCLUSIONS Respiratory rehabilitation protects against PPC and is more effective in moderate- and high-risk patients , but does not affect surgery-induced functional alterations Abstract Background Postoperative pulmonary complications ( PPCs ) are the most commonly reported complications after esophagectomy . The aim of this study was to examine the effect and feasibility of preoperative inspiratory muscle training-high intensity ( IMT-HI ) , and IMT-endurance ( IMT-E ) on the incidence of PPCs in patients following esophagectomy for esophageal cancer ( EC ) . Method A single-blind , r and omized , clinical pilot study was conducted between 2009 and 2012 . Forty-five participants were assigned to either IMT-HI or IMT-E.  Effectiveness was assessed by analyzing PPCs , length of hospital stay ( LOS ) , duration of mechanical ventilation , stay on the intensive care unit , and number of reintubations . Maximal inspiratory pressure and lung function changes were recorded pre- and post-training . Feasibility was assessed by IMT-related adverse events , training compliance , and patients ’ satisfaction . Results Thirty-nine patients could be analyzed , 20 patients in the IMT-HI arm and 19 patients in the IMT-E arm . The incidence of PPCs differed significantly between groups and was almost three times lower for the IMT-HI group ( 4 vs. 11 patients ; p = 0.015 ) . Other differences in favor of the IMT-HI group were LOS ( 13.5 vs. 18 days ; p = 0.010 ) and number of reintubations ( 0 vs. 4 patients ; p = 0.030 ) . Both interventions proved to be equally feasible . Conclusion Preoperative IMT-HI showed to be a promising , effective , and feasible intervention to reduce PPCs in EC patients undergoing esophagectomy . Further research with a larger sample size is recommended Objective : Investigation of the feasibility and preliminary effect of a short-term intensive preoperative exercise programme for elderly patients scheduled for elective abdominal oncological surgery . Design : Single-blind r and omized controlled pilot study . Setting : Ordinary hospital in the Netherl and s. Subjects : Forty-two elderly patients ( > 60 years ) . Interventions : Patients were r and omly assigned to receive a short-term intensive therapeutic exercise programme to improve muscle strength , aerobic capacity , and functional activities  , given in the outpatient department ( intervention group ; n = 22 ) , or home-based exercise advice ( control group ; n=20 ) . Main measures : Parameters of feasibility , preoperative functional capacity and postoperative course . Results : The intensive training programme was feasible , with a high compliance and no adverse events . Respiratory muscle endurance increased in the preoperative period from 259 ± 273 to 404 ± 349 J in the intervention group and differed significantly from that in the control group ( 350 ± 299 to 305 ± 323 J ; P<0.01 ) . Timed-Up- and -Go , chair rise time , LASA Physical Activity Question naire , Physical Work Capacity and Quality of Life ( EORTC-C30 ) did not reveal significant differences between the two groups . There was no significant difference in postoperative complications and length of hospital stay between the two groups . Conclusion : The intensive therapeutic exercise programme  was feasible and improved the respiratory function  of patients due to undergo elective abdominal surgery compared with home-based exercise advice Pulmonary complications after cardiac surgery are a leading cause of postoperative morbidity and mortality . Respiratory muscle weakness may contribute to the postoperative pulmonary abnormalities . We hypothesized that : ( 1 ) there is a decrease in inspiratory muscle strength ( PImax at residual volume ) and endurance ( Pmpeak/PImax ) following coronary artery bypass graft ( CABG ) ; ( 2 ) this weakness is associated with reduced pulmonary function tests ( PFTs ) , impaired gas exchange , and a higher rate of pulmonary complications ; and ( 3 ) prophylactic inspiratory muscle training ( IMT ) can prevent those changes . Eighty-four c and i date s for CABG , with ages ranging from 33 to 82 years , were evaluated prior to operation and r and omized into two groups : 42 patients underwent IMT using a threshold trainer for 30 min/day for 2 weeks , 1 month before operation ( group A ) ; 42 patients served as a control group and underwent sham training ( group B ) . There was a significant decrease in respiratory muscle function , PFTs , and gas exchange in the control group following CABG , whereas these parameters remained similar to those before entering the study in the training group . The differences between the groups were statistically significant . In addition , 11 ( 26 % ) patients in the control group but only 2 ( 5 % ) in the training group needed postsurgical mechanical ventilation longer than 24 hours . CABGs have a significant deteriorating effect on inspiratory muscle function , PFTs , and arterial blood gases . The decrease in these parameters can be prevented by prophylactic inspiratory muscle training , which may also prevent postsurgical pulmonary complications
BACKGROUND Postoperative pulmonary complications ( PPCs ) have an impact on the recovery of adults after surgery .
It is therefore important to establish whether preoperative respiratory rehabilitation can decrease the risk of PPCs and to identify adults who might benefit from respiratory rehabilitation .
OBJECTIVES Our primary objective was to assess the effectiveness of preoperative inspiratory muscle training ( IMT ) on PPCs in adults undergoing cardiac or major abdominal surgery .
We looked at all-cause mortality and adverse events .