title: Chest physiotherapy does not improve the outcome in laparoscopic fundoplication and vertical-banded gastroplasty Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Effects of periodic positive airway pressure by mask on postoperative pulmonary function. Physiotherapy after coronary artery surgery: are breathing exercises necessary? National survey of the usage of lung expansion modalities for the prevention and treatment of postoperative atelectasis following abdominal and thoracic surgery. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Absence of benefit of incentive spirometry in low-risk patients undergoing elective cholecystectomy. A controlled randomized study. Incentive spirometry for tracheostomy and laryngectomy patients. Incentive spirometry does not enhance recovery after thoracic surgery A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Postthoracotomy respiratory muscle mechanics during incentive spirometry using respiratory inductance plethysmography. Prophylaxis against pulmonary complications in patients undergoing gall-bladder surgery. A comparison between early mobilization, physiotherapy with and without bronchodilatation. Breath-stacking increases the depth and duration of chest expansion by incentive spirometry. Risk factors for postoperative pneumonia. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations
abstract: 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 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 Postoperative pulmonary complications , alveolar-arteriolar oxygen difference ( [A-a]O2-diff ) , peak expiratory flow ( PEF ) and forced vital capacity ( FVC ) were compared in patients using continuous positive airway pressure ( CPAP ) and positive expiratory pressure ( PEP ) administered  by face mask  against those of a control  group using  a deep-breathing device ( Triflo ) .  Forty-three consecutive , r and omized patients undergoing elective upper abdominal surgery were included .  CPAP , PEP and Triflo were administered for 30 consecutive breaths in every waking hour for three days postoperatively . The (A-a)O2-difference increased equally and significantly in the three groups after surgery , reaching a maximum on the first postoperative day . After this day , however , (A-a)O2-diff decreased in the CPAP and PEP groups , being significantly lower in the PEP group compared to the control group , two days postoperatively ( p less than 0.05 ) and significantly lower in both the PEP and CPAP groups three days postoperatively ( p less than 0.001 and p less than 0.05 , respectively . ) PEF did not differ significantly between the groups before or after surgery , while FVC was significantly higher in the PEP and CPAP groups , compared to control , on the third postoperative day ( p less than 0.05 ) . Atelectatic consolidation was observed in six of 15 patients in the control group three days postoperatively , the incidence being significantly lower in both the PEP group ( 0 of 15 , p less than 0.001 ) and the CPAP group ( one of 13 , p less than 0.05 ) . We concluded that periodic face mask administration of CPAP and PEP are superior to deep breathing exercises with respect to gas exchange , preservation of lung volumes and development of atelectasis after upper abdominal surgery . We also conclude that the simple and commercially available PEP mask is as effective as the more complicated CPAP system 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 A national survey of hospitals was conducted to evaluate the usage of lung expansion maneuvers in the prevention and management of  postoperative atelectasis associated with abdominal and thoracic surgery . Equal numbers of hospitals were r and omly selected from the nine American Hospital Association regions and from bed-size groups of 50 to 200 beds , 201 to 400 beds , and greater than 400 beds .  Preoperative and postoperative prophylactic therapy was found to be similar in all groups except for a lower usage of  intermittent positive-pressure breathing ( IPPB ) in the western third of the United States compared with the central third . In the treatment of postoperative atelectasis there are significant differences in the use of  chest physical therapy  , IPPB , and  intermittent continuous positive airway pressure  based on hospital size . Objective measurements of tidal volume or inspiratory capacity as a guide to therapeutic decisions are performed more frequently in the western regions . Surgical statistics relative to the number of abdominal and surgical procedures done and the incidence of postoperative atelectasis are also presented 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 To determine the potential benefit of incentive spirometry , which has been advocated to prevent pulmonary complications after upper-abdominal surgery , we compared a group of patients receiving incentive spirometry  to another group receiving no specialized postoperative respiratory care . Forty patients in the American Society of Anesthesiologists ' class 1 and 2 who were undergoing cholecystectomy ( through right subcostal incision ) were included in the study and were r and omly allocated to one of the two groups . Patients receiving incentive spirometry were encouraged by a specialized respiratory physiotherapist to breathe deeply for five minutes hourly , 12 times daily , for three postoperative days . No statistically significant difference between the two groups was found in the radiologic evidence of postoperative pulmonary complications , arterial oxygen pressure , spirometric measurement , and clinical evaluation at the second or fourth postoperative day ( or both ) . In particular , deterioration on the chest x-ray film at the fourth postoperative day was observed in eight of 20 patients in the group receiving incentive spirometry and in six of 20 in the control group . Our study confirms the postoperative deterioration of respiratory function after upper-abdominal surgery and demonstrates the lack of therapeutic values of  incentive spirometry  in these patients at low risk for pulmonary complications Sustained maximal inspiration ( incentive spirometry ) is used for the prevention and management of atelectasis in major abdominal and thoracic surgery . Patients with head and neck surgery are predisposed to postoperative disturbances in lung function after extensive surgical resection , immobilization , or significant chest wall deformity from various reconstructive procedures . The patient often requires tracheostomy or permanent laryngeal stoma . A prospect i ve clinical study on patients with major head and neck surgery was conducted to evaluate the use of incentive spirometry to improve postoperative lung function . An adaptor was first design ed to allow patients with tracheostomy tubes to use the spirometers . Parameters studied include vital signs , arterial blood gases ( A-a gradient ) , and pulmonary function test . Significant improvement of lung function and lack of complication warrant the use of incentive spirometry in postoperative head and neck surgery patients Objective : To investigate the additional effect of incentive spirometry to chest physiotherapy to prevent postoperative pulmonary complications after thoracic surgery for lung and esophageal resections . Design : R and omized controlled trial . Setting : University hospital , intensive care unit , and surgical department . Patients : Sixty‐seven patients ( age , 59 ± 13 yrs ; forced expiratory volume in 1 sec , 93 % ± 22 % predicted ) undergoing elective thoracic surgery for lung ( n = 40 ) or esophagus ( n = 27 ) resection . Interventions : Physiotherapy ( breathing exercises , huffing , and coughing ) ( PT ) plus incentive spirometry ( IS ) was compared with PT alone . Measurements and Main Results : Lung function , body temperature , chest radiograph , white blood cell count , and number of hospital and intensive care unit days were all measured . Pulmonary function was significantly reduced after surgery ( 55 % of the initial value ) and improved significantly in the postoperative period in both groups . However , no differences were observed in the recovery of pulmonary function between the groups . The overall score of the chest radiograph , based on the presence of atelectasis , was similar in both treatment groups . Eight patients ( 12 % ) ( three patients with lobectomy and five with esophagus resection ) developed a pulmonary complication ( abnormal chest radiograph , elevated body temperature and white blood cell count ) , four in each treatment group . Adding IS to regular PT did not reduce hospital or intensive care unit stay . Conclusions : Pulmonary complications after lung and esophagus surgery were relatively low . The addition of IS to PT did not further reduce pulmonary complications or hospital stay . Although we can not rule out beneficial effects in a subgroup of high‐risk patients , routine use of IS after thoracic surgery seems to be ineffective 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 We undertook this study to characterize the postthoracotomy compartmental displacement and respiratory mechanical changes occurring during and after the performance of the incentive spirometry maneuver . We also evaluated the effect of recumbency angle on compartmental recruitment .  Sixteen patients were r and omized to perform incentive spirometry either at 30 degrees or 60 degrees recumbency angle . They were studied using respiratory inductance plethysmography  to measure tidal volume , respiratory frequency , inspiratory time , rib cage motion/tidal volume ratio , inspiratory duty cycle , and inspiratory flow . Patients were studied before surgery and on postoperative days 1 and 3 . Statistical analysis was accomplished using multiple measures ANOVA with post-hoc Student 's t-tests when appropriate . Preoperative incentive spirometry augmented VT by increasing both VT/TI and TI . Postoperatively , the incentive recruitment of VT was reduced , a result of a decrease in TI and TI/TTOT ; VT/TI was unchanged . There was postoperative decrease of AB and AB/VT during incentive spirometry , greatest in the 60 degrees group . Our results characterize the nature of the respiratory recruitment afforded by incentive spirometry , before and after thoracotomy . We also found evidence of postthoracotomy diaphragmatic derecruitment during incentive spirometry exacerbated by a high recumbency angle A r and om comparison of early mobilization and chest physiotherapy ( mainly breathing exercises ) with or without bronchodilatating inhalations for prophylaxis against pulmonary complications in patients undergoing elective gall-bladder surgery is presented . The operation was performed with a subcostal incision and peroperatively , intercostal nerve block was administered . Preoperative pulmonary status ( dynamic volume spirometry , peak expiratory flow rate , arterial blood gas analysis ) showed no differences between the groups , and postoperative blood gas analysis and pulmonary X-ray or evident clinical findings did also not show any differences between the groups . Thus early mobilization was as effective in our study as the other prophylactic treatments . In patients without pulmonary disease perhaps early mobilization and efficient analgesia after surgery is as effective as more re source dem and ing physiotherapy for prophylaxis against postoperative pulmonary complications Although the objective of incentive spirometry is to achieve and hold high lung volumes , many patients with pain or weakness are unable to sustain the effort needed to perform effective exercises . We question ed whether using a one-way valve to prevent exhalation would allow rest between inspiratory efforts and cause volume to cumulate during successive tidal efforts , improving both the depth and duration of the inspiratory maneuver . We studied 26 cooperative but naive patients recovering from surgery , trauma , or critical illness whose pain or weakness impaired ability to achieve and sustain deep inspiration . All subjects breathed via mouthpiece from a spirometer prefilled with 100 % oxygen . Three different maneuvers were performed in r and om order by all subjects : ( 1 ) st and ard inspiratory capacity without valve or inspiratory hold , ( 2 ) inspiratory capacity ( IC ) with breathholding aided by a one-way valve , and ( 3 ) uncoached breath-stacking , during which successive tidal breaths were cumulated by one-way valving . A fourth maneuver was added in the last 13 subjects studied : an initial coached IC effort with subsequent valved stacking of tidal efforts . When compared with IC , " breath stacking " ( valved ) maneuvers increased inspired volume by an average of 15 to 20 % ( p less than 0.05 ) . More importantly , there was a severalfold increase in the time over which high lung volume was sustained ( p less than 0.001 ) . Our results indicate that one-way valving helps to achieve and sustain deep inspiration , even in uncoached patients Prospect ively studied were 520 patients undergoing elective thoracic , upper abdominal and lower abdominal surgeries  to analyze risk factors for postoperative pneumonias . Over-all , pneumonias developed in 91 of the 520 patients studied ( 17.5 percent ) . The acquisition of pneumonia was highly associated with preoperative markers of the severity of underlying diseases such as low serum albumin concentrations on admission ( P less than 0.005 ) and high American Society of Anesthesiologists pre-anesthesia physical status classification ( P less than 0.0001 ) . History of smoking ( P less than 0.001 ) , longer preoperative stays ( P less than 0.0001 ) , longer operative procedures ( P less than 0.0001 ) and thoracic or upper abdominal sites of surgery ( P less than 0.0001 ) were also significant risk factors for postoperative pneumonias . Although massive obesity , old age and male sex were also associated with increased incidences of pneumonia , statistical significance was lost when these variables were controlled for site or duration of surgery . We were able to identify risk factors for pneumonia and to define a sub population of patients in which the risk of pneumonia was negligible . The acquisition of pneumonia by a low-risk patient should alert the physician to the possibility of a potentially preventable nosocomial infection 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
target: Presently , the evidence does not support the use of IS for decreasing the incidence of PPCs following cardiac or upper abdominal surgery
background: OBJECTIVE To systematic ally review the evidence examining the use of incentive spirometry ( IS ) for the prevention of  postoperative pulmonary complications ( PPCs ) .