title: Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery. Size is everything – large amounts of information are needed to overcome random effects in estimating direction and magnitude of treatment effects Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery [Prevention of postoperative pulmonary complications after heart-lung surgery. Comparison of 3 different mask physiotherapy regimens]. Pneumonia after cardiac surgery is predictable by tracheal aspirates but cannot be prevented by prolonged antibiotic prophylaxis. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Three different mask physiotherapy regimens for prevention of post-operative pulmonary complications after heart and pulmonary surgery Physiotherapy after coronary artery surgery: are breathing exercises necessary? The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. [Mask physiotherapy for prevention of pulmonary complications after heart surgery. A controlled study]. Mask physiotherapy in patients after heart surgery: A controlled study Determinants of hospital charges for coronary artery bypass surgery: the economic consequences of postoperative complications. Effects of conventional physiotherapy, continuous positive airway pressure and non‐invasive ventilatory support with bilevel positive airway pressure after coronary artery bypass grafting Use of a nasal continuous positive airway pressure mask in the treatment of postoperative atelectasis in aortocoronary bypass surgery. Chest physiotherapy after coronary artery bypass graft surgery--a comparison of three different deep breathing techniques. Chest Physiotherapy Fails to Prevent Postoperative Atelectasis in Children After Cardiac Surgery Comparison of incentive spirometry and intermittent positive pressure breathing after coronary artery bypass graft. Continuous positive airway pressure by mask in patients after coronary surgery The effect of physical therapy on respiratory complications following cardiac valve surgery. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Incentive breathing devices and chest physiopathy: a controlled therapy. Postoperative physical therapy after coronary artery bypass surgery. Pain management in cardiac surgery patients: comparison between standard therapy and patient-controlled analgesia regimen.
abstract: One hundred twenty patients undergoing coronary artery surgery completed a r and omized controlled study design ed to investigate whether prophylactic chest physiotherapy affected the incidence of postoperative pulmonary complications . Group 1 patients received no preoperative or postoperative chest physiotherapy . Group 2 patients received preoperative education and instruction in breathing and coughing exercises and postoperative supervision and assistance in performing the same . These exercises were supervised by a physiotherapist twice per day on the first 2 postoperative days and once per day on the 3rd and 4th postoperative days . Physiotherapy for group 3 patients was the same as for group 2 patients except that patients were seen by a physiotherapist 4 times per day on the first 2 postoperative days and twice per day on the 3rd and 4th postoperative days . Group 2 and 3 patients were instructed to practice breathing and coughing exercises every hour . Overall , an incidence of clinical ly significant postoperative pulmonary complications of 7.5 percent was demonstrated . In general , these patients demonstrated lower levels of preoperative pulmonary function and very low early postoperative oxygenation compared with those who did not develop pulmonary complications . There was no indication that the incidence or severity of fever , hypoxemia , chest roentgenologic abnormalities or clinical ly significant postoperative pulmonary complications was different between groups . These results suggest that the necessity for prophylactic chest physiotherapy after routine coronary artery surgery should be review ed Abstract  Variability  in patients ' response to interventions in pain and other clinical setting s is large . Many explanations such as trial methods , environment or culture have been proposed , but this paper sets out to show that the main cause of the variability may be r and om chance , and that if trials are small their estimate of magnitude of effect may be incorrect , simply because of the r and om play of chance . This is highly relevant to the questions of ‘ How large do trials have to be for statistical accuracy ? ’ and ‘ How large do trials have to be for their results to be clinical ly valid ? ’ The true underlying control event rate ( CER ) and experimental event rate ( EER ) were determined from single‐dose acute pain analgesic trials in over 5000 patients . Trial group size required to obtain statistically significant and clinical ly relevant ( 0.95 probability of number‐needed‐to‐treat within ±0.5 of its true value ) results were computed using these values . Ten thous and trials using these CER and EER values were simulated using varying group sizes to investigate the variation due to r and om chance alone . Most common analgesics have EERs in the range 0.4–0.6 and CER of about 0.19 . With such efficacy , to have a 90 % chance of obtaining a statistically significant result in the correct direction requires group sizes in the range 30–60 . For clinical relevance nearly 500 patients are required in each group . Only with an extremely effective drug ( EER>0.8 ) will we be reasonably sure of obtaining a clinical ly relevant NNT with commonly used group sizes of around 40 patients per treatment arm . The simulated trials showed substantial variation in CER and EER , with the probability of obtaining the correct values improving as group size increased . We contend that much of the variability in control and experimental event rates is due to r and om chance alone . Single small trials are unlikely to be correct . If we want to be sure of getting correct ( clinical ly relevant ) results in clinical trials we must study more patients . Credible estimates of clinical efficacy are only likely to come from large trials or from pooling multiple trials of conventional ( small ) size OBJECTIVE : Internists frequently evaluate preoperative cardiopulmonary risk and comanage cardiac and pulmonary complications , but the comparative incidence and clinical importance of these complications are not clearly delineated . This study evaluated incidence and length of stay for both cardiac and pulmonary complications after  elective laparotomy .  DESIGN : Nested case-control . SETTING : University-affiliated Department of Veterans Affairs Hospital . PATIENTS : Computerized registry of all 2,291 patients undergoing elective abdominal operations from 1982 to 1991.MEASUREMENT AND MAIN RESULTS : Strategy for ascertainment and verification of complications was systematic and explicit . The charts of all 116 patients identified by the registry as having complications and 412 ( 19 % ) r and omly selected from 2,175 remaining patients were review ed to verify presence or absence of cardiac or pulmonary complications , using explicit criteria and independent abstract ion of pre- and postoperative components of charts . From these 528 vali date d cases and controls ( 23 % of the cohort ) , 96 cases and 96 controls were matched by operation type and age within ten years . Hospital and intensive care unit stays were significantly longer ( p<0.0001 ) for the cases than for the controls ( 24.1 vs 10.3 and 5.8 vs 1.5 days , respectively ) . All 19 deaths occurred among the cases . Among the cases , pulmonary complications occurred significantly more often than cardiac complications ( p<0.00001 ) and were associated with significantly longer hospital stays ( 22.7 vs 10.4 days , p=0.001 ) . Combined cardiopulmonary complications occurred among 26 % of the cases . Misclassification-corrected incidence rates for the entire cohort were 9.6 % ( 95 % CI 7.2–12.0 ) for pulmonary and 5.7 % ( 95 % CI 3.8–7.7 ) for cardiac complications . CONCLUSIONS : For noncardiac surgery , previous research has focused on cardiac risk . In this study , pulmonary complications were more frequent , were associated with longer hospital stay , and occurred in combination with cardiac complications in a substantial proportion of cases . These results suggest that further research is needed to fully characterize the clinical epidemiology of postoperative cardiac and pulmonary complications and better guide preoperative risk assessment 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 BACKGROUND The purpose of this study was to assess the value of tracheal aspirate as a predictor of pneumonia after coronary artery bypass grafting and to evaluate the efficacy of prolonged perioperative antibiotic prophylaxis . METHODS Tracheal aspirates of 500 patients undergoing coronary artery bypass grafting were taken immediately after intubation and analyzed for microorganisms by Gram stain and semiquantitative microbiologic cultures . All patients received 2 g ceftriaxone as a single-dose perioperative antibiotic prophylaxis before operation . Results of Gram stains were available before the patients were transferred to the intensive care unit . After the results were known , both groups of patients ( positive Gram stain , group 1 ; negative Gram stain , group 2 ) were r and omly assigned to either conventional antibiotic prophylaxis ( A ) , consisting of ceftriaxone 2 g on postoperative day 1 , or prolonged antibiotic prophylaxis ( B ) , with ticarcillin + clavulanic acid 3 x 5.2 g during 72 hours . RESULTS From 500 patients , 91 had a positive Gram stain whereas 409 had a negative one . The incidence of pneumonia was significantly higher in patients with preoperative positive tracheal aspirates ( 15.3 % ) than in patients with a negative one ( 3.6 % ; p < 0.01 ) . However , prolonged prophylaxis did not reduce the rate of postoperative pneumonia , which was as high as 13 % in untreated positive patients versus 17 % in treated positive patients , and 2 % in untreated negative patients versus 4 % in treated patients . In patients who had pneumonia , there was a high correlation between the microorganisms found in preoperative aspirates and those observed when aspirates were repeated ( 100 % correlation in patients with conventional antibiotic prophylaxis and 87 % in those with prolonged prophylaxis ) . CONCLUSIONS Early postoperative pneumonia ( < 7 days ) is most likely caused by microorganisms that colonize the respiratory tract before operation . The risk of pulmonary infection after coronary artery bypass grafting can be predicted from the preoperative tracheal aspirates . Prolonged perioperative antibiotic prophylaxis has no efficacy in reducing the incidence of pulmonary infections 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 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 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 BACKGROUND AND PURPOSE The purpose of this study was to determine whether the addition of incentive spirometry ( IS ) to postoperative pulmonary physical therapy is more effective than physical therapy alone in reducing postoperative pulmonary complications in high-risk patients after coronary artery bypass grafting ( CABG ) . Patients were given the spirometer and instructed in its use , as often occurs in clinical setting s. SUBJECTS Patients with chronic airflow limitation following CABG ( N = 185 ) participated . METHODS Subjects were r and omly assigned to receive either postoperative pulmonary physical therapy ( breathing exercises , secretion removal , mobility ) or physical therapy combined with IS . RESULTS No difference was found between the two groups in atelectasis , spirometry , oxygen saturation , pulmonary infection , or hospital stay . CONCLUSION AND DISCUSSION Incentive spirometry combined with physical therapy is no more effective than postoperative physical therapy alone in reducing atelectasis for this population . Use of the spirometer , however , was not monitored , and although the study mimicked practice as it often occurs , the effectiveness of the spirometer can not be fully evaluated 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 ) This is a prospect i ve study of 500 consecutive patients having coronary artery bypass surgery ; mean hospital charge from time of surgery to discharge was + 11,900 + /- 12,700 . Multiple regression analysis was performed using preoperative variables and postoperative complications . No preoperative clinical feature was a significant predictor of higher average charge . Sternal wound infection ( p = 0.0001 ) , respiratory failure ( p = 0.0001 ) and left ventricular failure ( p = 0.017 ) were associated with higher average hospital charge . The absence of any complication predicted a lower average charge , and postoperative death ( 4.4 + /- 4.5 days after surgery ) was also associated with lower average charge . A cost equation was developed : hospital charge equalled $ 11,217 + $ 41,559 of sternal wound infection , + $ 28,756 for respiratory failure , + $ 5,186 for left ventricular failure , - $ 1,798 for no complication and - $ 6,019 for death . Recognition of the influence of complications on charges suggests that low average charges can only be achieved by surgical programs with a low complication rate Background : Coronary artery bypass graft ( CABG ) surgery with the use of mammary arteries is associated with severe alteration of lung function parameters . The purpose of the present study was to compare the effect on lung function tests of conventional physiotherapy using incentive spirometry ( IS ) with non‐invasive ventilation on continuous positive airway pressure ( CPAP ) and with non‐invasive ventilation on bilevel positive airway pressure ( BiPAP or NIV‐2P ) Pulmonary oxygen transfer , defined by PaO2/FIO2 , and radiologic presence of atelectasis were measured pre- , intra- , and postoperatively to postoperative day 9 in elective cardiac aortocoronary bypass surgical patients , who were r and omly allocated either to receive 18 h PEEP while on the ventilator followed by 12 h of nasal continuous positive airway pressure ( nasal CPAP ) or  to  be control subjects .  The two groups were comparable in age , sex , forced expiratory volume in 1 sec ( FEV1 ) , the ratio of FEV1 over forced vital capacity ( FVC ) , time on pump , units of blood transfused , New York Heart Association grading , and cardiac performance indices . The PaO2/FIO2 was significantly ( p less than .05 ) better from half an hour after extubation until 24 h postextubation in the nasal CPAP group , but was decreased for the remainder of the study in both groups . Incidence of atelectasis/consolidation was not different in both groups during the study period . We conclude that nasal CPAP is well tolerated as a treatment of hypoxemia in the immediate postoperative period of aortocoronary bypass patients . CPAP does not change the course of postoperative atelectasis The effectiveness of three deep breathing techniques was evaluated in 98 male patients after coronary artery bypass graft surgery in a r and omized trial . The techniques examined were deep breathing with a blow bottle-device , an inspiratory resistance-positive expiratory pressure mask ( IR-PEP ) and performed with no mechanical device .  Pulmonary function and roentgenological changes were evaluated . Four days post-operatively there were significantly decreased vital capacity , inspiratory capacity , forced expiratory volume in 1 second , functional residual capacity , total lung capacity and single-breath carbon monoxide diffusing capacity in all three groups ( p < 0.0001 ) . No major differences between the treatment groups were found , but the impairment in pulmonary function tended to be less marked using the blow bottle technique . The Blow bottle group had significantly less reduction in total lung capacity ( p = 0.01 ) compared to the Deep breathing group , while the IR-PEP group did not significantly differ from the other two groups In a prospect i ve , r and omized study , the effectiveness of chest physiotherapy ( CPT ) was evaluated in preventing postoperative atelectasis in children after heart surgery . Postoperative clinical variables and chest x-ray findings of atelectasis were compared in two groups : 19 patients receiving CPT and 25 patients not receiving CPT ( NCPT ) . Chest physiotherapy was associated with significantly more frequent ( p less than 0.01 ) and more severe ( p less than 0.01 ) atelectasis than NCPT . Atelectasis was not significantly associated with temperature elevation , age , or presence of preoperative left-to-right shunt Fifty-two patients were r and omized to receive either incentive spirometry ( IS ) or intermittent positive pressure breathing ( IPPB ) in addition to conventional chest physical therapy following coronary artery bypass grafting .  Slow vital capacity and peak expiratory flow readings decreased rapidly and to an equal extent in both groups after surgery , and partly recovered by the sixth postoperative day ( POP ) . Arterial PO2 values were similar for the groups on the first three POPs . On the POPs 2 , 3 , and 6 , the number of chest films showing atelectases as well as the number of individual patients having atelectases revealed no statistically significant differences between the two groups . Based on the three variables studied , we consider both devices equal in efficiency after coronary surgery Thirty patients who underwent coronary artery bypass grafting were r and omized to receive 30 % oxygen by mask either with an ambient airway pressure or with 7.4 mmHg ( 1 kPa ) continuous positive airway pressure ( CPAP ) for 8 h after extubation . Arterial blood oxygen tension ( Pao2 ) decreased remarkably in the control group after extubation ( from 19.2± 5.3 kPa to 12.4 ± 2.7 kPa ) but less in the CPAP group ( from 16.4 ± 3.3 kPa to 14.0 ± 2.1 kPa ) . On the second postoperative morning Pao2 was equally low in both groups ( control : 8.4 ± 1.5 kPa , CPAP : 8.9 ± 1.9 kPa ) . Atelectatic areas were seen with similar frequency in both groups , 17 % ( whole material ) on the first and 50 % on the second postoperative morning . Atelectasis was more common in patients with internal thoracic artery grafting and /or pleural drainage . In conclusion , CPAP therapy was well tolerated , and minimized the decrease in Pao2 after extubation , but could not prevent the poor oxygenation or the late development of atelectatic areas on the second postoperative day 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 Of 38 patients undergoing median sternotomy for cardiac operations all developed profound restrictive defects in pulmonary function during the first 72 h after tracheal extubation . Although decreased lung volumes were refractory to correction by vigorous , aggressive pulmonary therapy during this period , frequent and supervised treatment may prevent further deterioration in pulmonary function . The overall incidence of pneumonia was only 3 % ( 1/38 ) . Continuous positive airway pressure delivered by mask proved to be a nearly effortless form of postoperative respiratory therapy that was less painful than incentive spirometry or coughing and deep breathing , and therefore may be preferable Following cardiac operations , 145 patients were treated with either intermittent positive-pressure breathing ( IPPB ) , blod bottles , or an incentive spirometer in an attempt to alter the incidence of atelectasis . Pulmonary complications occurred in 30 % of the patients receiving IPPB , 15 % of those using an incentive spirometer , and 8 % of those using blow bottles .  Gastrointestinal side-effects occurred in 20 % of the IPPB group and were rare in other groups . The cost of IPPB is also considerably greater than either incentive spirometry or blow bottles . IPPB is not essential to prevention of atelectasis in postoperative cardiac surgical patients and may be inferior to other methods Intestinal ischemia should be suspected in any patient following aortic surgery who has pain out of keeping with the operation , postoperative diarrhea ( with or without bleeding ) or an unexplained metabolic acidosis . Ten such cases of intestinal ischemia were identified during a 10-year period at the Toronto General and Toronto Western hospitals . Six occurred following repair of a ruptured abdominal aneurysm , one followed elective aneurysmectomy and three followed elective bypass for occlusive disease . The overall mortality was 70 % . Transmural bowel infa rct ion was found in six patients ( all died ) , while four patients had partial-thickness injury ( one died , three had late strictures ) . Potentially preventable factors in each patient , either single or multiple , were identified and are discussed . Emphasis on early diagnosis is stressed , because once transmural necrosis has occurred the prognosis is poor Coronary artery bypass surgery is frequently complicated by postoperative atelectasis . Although routinely prescribed , the efficacy of any specific chest physical therapy is not well established . We studied patients at a university center undergoing elective coronary artery bypass surgery . Based upon chest X-ray criteria at extubation , patients ( n = 228 ) were classified as demonstrating greater or lesser degrees of atelectasis . Those with a lesser degree of atelectasis were r and omized to receive either early mobilization or sustained maximal inflations ( SMI ) . Those with greater a degree of atelectasis were separately r and omized to receive either SMI or single-h and ed percussions ( SSP ) . We found the extent of atelectasis at extubation did not predict the risk of developing pneumonia . Hospital stays and intensive care unit stays were similar regardless of treatment . Physical therapy costs were highest in the most labor-intensive therapy group ( SSP ) . We conclude that postoperative respiratory dysfunction is common but does not commonly cause significant morbidity or prolong hospital stay . Adding SMI to patients with minimal atelectasis at extubation does not improve clinical outcomes . Similarly , adding SSP to patients with marked atelectasis does not improve outcomes over those obtained with SMI and early ambulation OBJECTIVE To compare st and ard nurse-based pain therapy with a patient-controlled analgesia ( PCA ) regimen . DESIGN Prospect i ve , r and omized study . SETTING Single-institutional , clinical investigation in an urban , university-affiliated hospital . PARTICIPANTS Sixty patients undergoing elective first-time cardiac surgery were included . INTERVENTIONS In 30 patients , a st and ard analgesic regimen was used , and in 30 patients , a PCA regimen was used . The perioperative and postoperative management was similar for all patients . MEASUREMENTS AND MAIN RESULTS Degree of sedation , satisfaction , and pain ( by visual analog scale [ VAS ] ) was assessed within the first 3 postoperative days . Vital capacity ( VC ) and forced expiratory volume in 1 second ( FEV1 ) were measured using a portable spirometry system . Cortisol and troponin T ( TnT ) plasma levels were also measured . The expectation of pain was similar in both groups , and the postoperative pain score was significantly lower in the PCA than in the st and ard group throughout the study period . Significantly more  piritramid  was used in the PCA ( total , 75.6 + /- 33.4 mg ) than in the st and ard group ( total , 20.1 + /- 31.9 mg ) . VC and FEV1 were significantly lower in the st and ard group compared with the PCA patients . Cortisol and TnT plasma levels were similar in both groups . Frequency of side effects were similar for both groups . CONCLUSION Because of the beneficial effects with regard to degree of pain and satisfaction , pain management using PCA systems can be recommended for cardiac surgery patients . It appears to be superior to st and ard nurse-based pain therapy
target: The usefulness of respiratory physiotherapy for the prevention of pulmonary complications after cardiac surgery remains unproved .
background: OBJECTIVE To assess whether respiratory physiotherapy prevents pulmonary complications after cardiac surgery .