RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATIONOF SUBJECTS FOR
DESERTATION
1. / Name of the candidate & address / Divya Rajan,# 20&21, 2nd B, B-block,
8th A cross, Mathikere,
Bangalore – 54.
2. / Name of the Institution / Kempegowda Institute of Physiotherapy, Bangalore.
3. / Course of the study and subject / M.P.T. (Cardio-Respiratory Disorders &
Intensive care)
4. / Date of admission to the course / 9th June 2008
5. / Title of the Topic
“A comparative study between the effectiveness of incentive spirometry and deep breathing exercises in improving pulmonary function following cardiac valve replacement surgery.”
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8 / Brief resume of the Intended work
6.1 Need for the study:
The heart is a muscle that pumps blood into arteries throughout the body. The human heart has four chambersand four heart valves which regulates blood flow through the heart.
The valves present in the heart are :
- The Tricuspid valve regulates blood flow between the right atrium and right ventricle.
- The Pulmonary valve controls blood flow from the right ventricle into the pulmonary arteries, which carry blood to the lungs.
- The Mitral valve lets the oxygenated blood from the lungs to pass from the left atrium into the left ventricles.
- The Aortic valve opens the way for oxygenated blood to pass from the left ventricle into the Aorta. It is the body’s largest artery and delivers blood to all parts of the body.
Valvular heart disease occurs due to abnormality of one or more heart valves. The heart valves can get damaged due to infection, rheumatic fever, ageing process, or it may be a birth defects. Valvular disease caninvolve a valve that does not close properly (insufficiency) or due to narrowing (stenosis). The end result of any defective heart valve is decrease in the pumping activity of blood. The over worked heart may fail causing symptoms such as dizziness, chest pain, shortness of breath, fatigue and fluid retention. As these symptoms worsen, a decision needto be made on whether the heart valve needs to be repaired or replaced.
The diseased heart valves can be replaced with mechanical or biological prostheses. The three most commonly used mechanical prostheses are the ball, cage, tilting single disc and tilting by leaflet valve1.
Clinical manifestations of post operative pulmonary dysfunction (PPD) range from arterial hypoxemia in 100% of patients to acute respiratorydistress syndrome, which occurs in 0.4% to 2.0% of patients. An alterations in the mechanical properties of the lung leads to reduction in vital capacity, residual capacity and static and dynamic lung compliance.
Post operative pulmonary dysfunction refers to expected alterations in
pulmonary functions such as increased work of breathing, shallowrespiration, ineffective cough and hypoxemia2.
Changes in pulmonary functions and/or pulmonary complications mayoccur following upper abdominal and thoracic surgeries. In the earlypost operative period, that patient may not achieve sufficient inspiration;ciliary activity and coughing reflex decrease and mucus accumulation in the lung increase as a result the complication risk increases3.
The lung function will be measured by pulmonary function test (PFT) which is widely used to determine the existence of post operative pulmonary complications.Studies have shown that pulmonary function test values decrease in the early post operative period following any cardio thoracic surgeries. The incidence of pulmonary complication ranges between 30% to 50%. The complication ratio of the pulmonary function is related closely to factors such as type and site of incision, duration of the surgery, mechanical changes in the thorax which occur during the surgery,parenchymal deterioration of the lungs, the effect of anesthesia andinsufficient post operative cardio pulmonary physiotherapy3.
Incentive siprometry is a device which is used for improving the pulmonary
function. It is a device which provides patients with visual feed back when they inhale at a pre-determined flow rate /volume and sustain the inflationfor a minimum three seconds and then expire. Incentive spirometry alsorefers to as sustained maximum inspiration (SMI)4. Incentive spirometry improves lung volume, increases thoracic movement and increases ventilation.
Deep breathing exercises. These exercises are aimed at increasing lungvolume, redistribution of ventilation, improving gas exchange, increasingthoracic movement and mobilization of secretion5.
In my study I would like to compare the effectiveness of incentive Spirometry and deep breathing exercises in improving the pulmonaryDysfunction after cardiac valve replacement surgery.
Hypothesis-
Null Hypothesis –
It may be seen that deep breathing exercises and incentive Spirometry is not effective in improving pulmonary functionfollowing cardiac valve replacement surgery.
Alternate Hypothesis -
It may be seen that incentive spirometry is effective in improving pulmonary function following cardiac valve replacement surgery.6.2LITERATURE REVIEW:
- Rochelle Wynne et al. (2004) studied post operative pulmonary dysfunction in adults after cardiac surgery and concluded the effectiveness of pulmonary interventions applied for a longer time would be beneficial in the management of post operative pulmonary dysfunction1.
- N M Siafakas et al (1999) studied surgery and respiratory muscle dysfunction7.
- Charles Weissman et al. (1999) studied and found change in the pulmonary function after cardiac and thoracic surgery the structure and function of the respiratory system.
- Grant AF et al. (1962) studied recent advances in thoracic surgery in preventing postoperative pulmonary complication.
- Barna Babik et al. (2003) studied changes in respiratory mechanics during cardiac surgery and demonstrated that significant changes occur in the mechanical properties of the respiratory system during cardiac surgery6.
- Valerie A.Larwrence et al. (2006) systematically reviewed the literature on interventions to prevent post operative pulmonary complications after non cardiac surgery and found good evidence on lung expansion therapy that reduces post operative pulmonary complications 8.
- Hulya Akdur et al. (2001) study was to compare pre and post operative pulmonary function test in adult patients who had intubation periods greater and less than 24 hours following elective open heart surgery. They agree that intensive and effective PT programs which are applied post operatively improve pulmonary functions, decrease the incidence of pulmonary complications and shorten the hospitalization period3.
- Jean N Crowe, Christine A Vradley et al. (1997) studied to determine whether the addition of incentives spirometry to post operative pulmonary physiotherapy is more effective than physical therapy alone in reducing post operative pulmonary complication in high risk patients after CABG and concluded there may be an added benefit by the addition of incentives spirometry to post operative pulmonary physiotherapy11.
- P Agostini et al. (2007) studied whether incentives spirometry is a useful intervention for patients after thoracic surgery and found incentive spiromerty is good measure of lung function and avoid post operative complications12.
- Jackle A Thomas et al. (1994) studied Are incentive siprometry, IPPB and deep breathing exercises effective in the prevention of post operative pulmonary complication after upper abdominal surgery and concluded incentives spirometry and deep breathing exercises to be more effective in preventing post operative pulmonary complications.
- Jose A Melendez et al. (1992) studied respiratory muscles mechanics during incentive spirometry and found the mechanism underlying the possibly beneficial effect is poorly understood.
- G.D Gale and D.E Sanders et al. (1980) studied treatment with IPPB and incentives spirometry was compared after heart surgery and cardio pulmonary by pass and found possibly IS treatment given more frequently may be more effective15.
- J.P fenninger and F.Roth et al. (1977) compared IPPB and incentive spirometer in post operative period and concluded incentive spirometer may be superior to IPPB as the patient is left to continue their own respiratory therapy.
- Josef Weindler et al. (2001) studied the efficacy of post operative incentives siprometer is influenced by the device specific imposed work of breathing and concluded incentive spirometer with low W B imp permit increased maximal sustained inspiration and thus enhanced incentive spirometer performance and therefore it might more suitable for use in post operative respiratory care14.
- Elisabeth Westerdahl et al. (2005) investigated the effect of deep breathing exercises on pulmonary function and concluded significant better pulmonary function16.
- John C Hall et al. (1996) studied the prevention of respiratory complication after abdominal surgery and concluded the most efficient regimen of prophylaxis against respiratory complication after abdominal surgery is deep breathing exercises for low risk patients and incentive spirometry for high risk patients.
1)To study the effectiveness of incentive spirometry in improving pulmonary function following cardiac valve replacement.
2)To study the effectiveness of deep breathing exercises in improving pulmonary function following cardiac valve replacement .
Material and Methods:
7.1Study design: Comparative evaluation study
7.2 Source of Data:
- Sri Jayadeva institute of cardiology.
- Kempegowda institute of medical sciences, Hospital and research center.
Sample size – 60 (GroupA-30, GroupB-30)
a) Materials used-
- PFT(Spirometer)
- Incentive Spirometer
- Pillows
- Bed
b) Inclusion Criteria-
- Subjects who have undergone cardiac valve replacement surgery.
- Subjects who are extubated and are on their second day of surgery are included in study.
- Subjects between age group of 45 – 60 years of age.
- Subjects include both sexes.
- Patients on ventilator longer than 72hrs.
- Nausea and vomiting.
- Bleeding from the site of incision.
- Hemodynamic complications.
- Intra operative myocardial infarction.
- Major blood loss.
- Marked Hypertension.
- Reduced cardiac output requiring the use of an intra-aortic balloon
- Post operative infections.
- History of smoking.
- History of any respiratory disorder.
other humans or animals? If so, please describe briefly:
Yes, an intervention on human subject’s area required.
Methodology:
- Consent of all patients will be taken.
- The subjects who are fulfilling inclusion and exclusion criteria will be included in the study.
- Subjects will be instructed on how to perform the interventions.
- Subjects are put in two groups. (group A – 30, group B – 30)
- Subjects will be treated daily after extubation from the second post operative day.
- Subjects in group A will be asked to perform incentive siprometry 10 breaths once per hour for 10 hrs when awake.
- Subjects in group B will be asked to perform 10 deep breaths once per hour for 10 hrs when awake.
- Pulmonary function test (PFT)
- Forced vital capacity (FVC)
- Forced expiratory volume in one second (FEV1)
- FEV1/FVC
- Pulmonary function test (PFT)
- Forced vital capacity (FVC)
- Forced expiratory volume in one second (FEV1)
- FEV1/FVC
Statistical Analysis-
- Student t-test
- Effect size
- Repeat measure ANOVA
Yes.
References:
1)Christopher Haslett, Edwin R Chilvers, Nicholas A Boon, Nicki R Colledge, John A A hunter. Davidson’s Principles and practice of medicine. 19th ed. Edinburgh: 1952. Pg467. Churchhill living stone.
2)Rochelle Wynne, Mari Botti. Post operative pulmonary dysfunction in adults after cardiac surgery with cardio pulmonary bypass: Clinical significance and implications for practice. Am J Crist Care 2004 Sep; 13 (5) : 384-93.
3)Hulya Akdur, Mine Gulden Polat, Zerrin Yigit, Umit Arabact, Semiramis Ozyilmaz, Hulya Nilgun Gureses. Effects of long intubation period on respiratory functions following open heart surgery. Jpn Heart J 2002 Sep; 43: 523-30.
4)Clinical practice guide line incentive spirometry. Rc Journal 1991 Dec; 36(12): 1402-05.
5)Johannes P Van De Leur, Linda Denehy. Post operative mucus clearance. 2004. Pg19. Lung biology in health and disease; 188.
6)Barna Babik, Tibor Asztalos, Ferenc Petak, Zoltan I Deak, Zoltan Hantos. Changes in respiratory mechanics during cardiac surgery. Anesth Analg 2003;96:1280-87.
7)N M Siafakas, I Mitrouska, D Bouros, D Georgopoulos. Surgery and the respiratory muscle. Thorax 1999;54:458-65.
8)Valerie A Lawrence, John E, Cornell, Gerald W, Smetana. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systemic review for the American college of physician.American college of physicians 2006 Apr 18; 144(8):596-08.
9)JA Rouckema, EJ Carol, JB Prins. The prevention of pulmonary complications after abdominal surgery in patients with noncompromised pulmonary status. Arch Surg 1988 Jan;123(1).
10)Patrick Pasquina, Martin R Tramer, Bernhard Walder. Prophylactic respiratory physiotherapy after cardiac surgery: Systemic review. BMJ 2003 Dec 13;327.
11)Jean M Crowe, Christine A Bradley. The effectiveness of incentive spirometry with physical therapy for high-risk patients after CABG. Phys Ther 1997 Mar;77(3):260-68.
12)Paula Agostini, Rachel Calvert, Hariharan Subramanian, Babu N aidu. Is incentive spirometry effective following thoracic surgery. Interact Cardiovasc Thorac Surg 2007 nov 24.
13) Krastins I, Corey ML, Mcleod A, Edmonds J, Levison H, Moes F. An evaluation of incentive spirometry in the management of pulmonary complications after cardic surgery in a pediatric population. Crit Care Med 1982 Aug; 10(8):525-8.
14)Josef Weindler, Ralph Thomas Kiefer. The efficacy of post operative incentive spirometry is influenced by the device-specific imposed work of breathing. Chest 2001; 119: 1858-64.
15)G D Gale, DE Sanders. Incentive spirometry : its value after cardiac surgery. Canda Anaesth Soc J. 1980 Sep; 27(5): 475-80.
16)Elisabeth Westerdahl, Birgitta Lindmark, Tomas Erikeson, Orjan Friberg, Goran Hedenstierna, Arne Tenling. Deep breathing exercises reduce atelectasis and improve pulmonary function after CABG surgery. Chest 2005 May 5; 128: 3482-3488.
17) E Westerdahl. Effects of deep breathing exercises after CABG. ACTA 2004.
18)ST. Joseph Health System Surgery Booklet [online]. Available from:
URL:
19) Clinical Pathway: Booklet Esophageal Surgery (OttawaHospital). [Online]. 2002 July. Available from: URL: ottawahospital.on.ca
9. / Signature of the Candidate: :
Divya Rajan
10. / Remarks of the Guide:The study is done to find the comparison between the effectiveness of incentive spirometry and deep breathing exercises in improving pulmonary function following cardiac valve replacement surgery
11. Names and designation of:
11.1 / Guide: / Prof. R. Balasaravanan, M.P.T
Principal, K.I.P.T
11.2 / Signature:
11.3 / Co-guide : / Dr. Rachana Shetty B.V
Lecturer, K.I.P.T
11.4 / Signature:
11.7 / Head of the Department: / Prof. R. Balasaravanan, M.P.T
Principal,
K.I.P.T
11.8 / Signature:
12. / 12.1 Remarks of the Chairman & Principal:
12.2 Signature
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