RMT in CABG

8/3/2019 RMT in CABG

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Respiratory muscle training

in patients submitted tocoronary arterial bypass graft

GF Barros, CS Santos, FB Granado,PT Costa, RL Prado, G GardenghiRev Bras Cir Cardiovasc 2010; 25(4): 483-490


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Introduction

The deleterious effect of cardiac surgery onpulmonary function may result in higher morbidity andmortality rates, longer hospital stay and higherexpenditure of physical and financial resources

Respiratory dysfunction in cardiac postoperative are

usually multifactorial and may be present, possiblybecause currently the CABG surgeries are performedin more vulnerable patients, with a higher tendency tolimited functional reserve and often associated witholder age


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Introduction

There are several factors that may compromise theventilatory capacity. The patients after CABG, becomeprone to develop pulmonary complications resulting fromintraoperative interventions, the hemodynamic status,type and duration of surgery, pain and placement of chest

tubes, resulting in reduced lung volume and capacity,changes in values of blood oxygenation, and especiallythe reduction in lung expansion, which facilitates theinstallation of atelectasis and pneumonia


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Introduction

There is respiratory muscle dysfunction related to the loss ofability to generate force significantly lower values ofmaximal inspiratory pressure (MIP) and maximal expiratorypressure (MEP) compared with preoperative values inpatients after cardiac surgery due to changes inmechanical properties of the lung and chest wall, resultingfrom various factors described above

Among the various procedures employed by the respiratoryphysiotherapy in post-CABG patients in general, the training

of respiratory muscle strength may be helpful in restoringlung function, promote more effectiveness in clearing theairway (effective cough) and prevent respiratory musclefatigue


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The Aim of Study

To demonstrate the impaired ventilatory capacityin the postoperative period in patients submittedto CABG.

To test the hypothesis that respiratory muscletraining (RMT), performed after surgery, mayimprove the ventilation capacity in thispopulation.


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Method


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Method

Randomized study, where 38 patients undergoing CABGwith cardiopulmonary bypass were divided into twogroups: 23 patients in the RMT group and 23 in the controlgroup (CO).

The RMT group performed conventional physical therapy +RMT; the CO group performed only conventionalphysiotherapy.

They were assessed at three time points (preoperatively,POD I and hospital discharge), variables: MIP and MEP,

pain, dyspnea (Borg), PEF, tidal volume and hospital days.


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Method

The conventional physiotherapy consisted of bronchialhygiene (vibrocompression composed of 4 sets of 6expiratory cycles, performed with the aid of hands on thesurface of the thorax, associated with postural drainage,

placing, based on the radiological image, the more affectedside of the lung upwards, and this position was maintainedfor 20 minutes to maximize the drainage of secretions) andtracheal aspiration when necessary (3-5 aspirations with theuse of probe number 12 or 14, by intubation with a maximum

duration of 10 seconds for each of aspirations). Both groups received physical therapy in 2 daily sessions

(morning and afternoon) as routine visits to the service.


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Method

RMT with Threshold device IMT. The protocol forRMT was performed as follows: 3 sets of 10repetitions, once a day for each day of hospitalizationafter surgery, with a load of 40% of the initial MIP,

obtained by analog manometer


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Result

In group C : 23 randomized patients

8 did not complete the treatment protocol

(2 had ventricular arrhythmias, 2 requiredreintubation during the ICU and 4 could not have their

data collected due to unscheduled hospital discharge inadvance)

15 remaining subjects


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Result

Fig.1 - (A) Tidal volume (TV)in both groups studied at 3time points: preoperative,POD 1 and at discharge.B) Peak expiratory flow

(PEF) in both groups studiedat 3 time points:

preoperative, POD 1 and atdischarge.CO = control group; RMTgroup = respiratory muscletraining group; lpm = liters

per minute * 1 PO vs.Preoperative; RMT vs. CO


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Discussion

The RMT group had higher values of TV at discharge,compared to the CO group a statistically significantdifference

The recovery observed in TV shows a greater capacity for

gas exchange in patients undergoing RMT, which maycontribute to better tissue oxygenation accompanied bylower rates of respiratory or metabolic disorders, fromthe standpoint of acid-base balance in this population.


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Discussion

The behavior of PEF in the 3 periods studied in both groups.represented by a significant drop in the values of the POD Icompared to preoperative values and significant recovery ofamounts only at the time of discharge, when considering the

RMT group The CO group showed a significant drop in the POD I, while

maintaining low values at discharge.

It is worth mentioning here that a higher PEF may beassociated with better ability to cough by part of the patients,

which is relevant in order to avoid accumulation of secretionsin the airways of the patients


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Result

Fig.2 - (A) MIP in bothgroups at 3 time points:

preoperative, POD 1 and

at discharge(B) MEP in two groupsinto 3 periods:

preoperative, POD 1 andat discharge.cmH2O = centimeters ofwater * 1 PO vs.Preoperative; RMT vs.CO


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Discussion

The values of MIP in the CO group showed a decline inthe ability of inspiratory force from the preoperative tothe POD I; keeping low values at the time of hospitaldischarge.

The values of MIP in the RMT group also showed adecline from preoperative to POD I and recoveredcompletely the ability of inspiratory force at the time ofhospital discharge


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Discussion

Regarding expiratory pressure, the CO group maintainedthe standard reduction in expiratory capacity

What draws attention in the analysis of this variable is thechanges of values of the RMT group, where the mean97.65 34.44 cmH2O in the preoperative period droppedto 72.30 32.38 cmH2O in the immediate postoperative,increasing to 99.21 30.00 cmH2O in the last day ofhospitalization, showing not only full recovery of the

initial value, as well as increase in the mean throughrespiratory muscle training, also statistically significant(P = 0.02).


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Result

Fig.3 - (A) of Borgdyspnea scale (in

points) applied to bothgroups at 3 time

points: preoperative,

POD 1 and atdischarge

(B) VAS of pain appliedto both groups at 3time points:

preoperative, POD 1and at discharge.

* 1 PO vs. preoperative


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Discussion

Levels of dyspnea did not increase significantly on thePOD I (P = 0.63)

The levels of pain increased in both groups on the POD I,decreasing at the time of hospital discharge (P = 0.00)

The fact that the pain in both groups has behavedsimilarly at all time points reinforces the benefits of RMTin patients undergoing the latter, whereas, with groupshaving the same pain perception, we value theintervention performed, excluding the pain factor as

limiting for the worst results in the CO group, whencompared with the RMT group.


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Discussion

Regarding the duration of CPB, all patients underwentCABG with CPB, with a mean of 60 16 minutes of usethereof, without significant differences between the twogroups (RMT: 62 12 vs CO: 57 21 minutes, P = 0.55).

Prolonged cardiopulmonary bypass time was directlyrelated to the incidence of postoperative pulmonarycomplications (Belud and Bernasconi, 2004).

Significant changes related to duration of CPB, with a

marked reduction of respiratory capacity in the groupundergoing CPB for 120 minutes (Nardi et al, 2006)


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Result and Discussion

In this study, patients in the RMT group remainedhospitalized for 7 2 days and patients in the CO groupfor 8 2 days and did not indicate at that time, significantdifferences regarding length of stay (P = 0.07).

We believe that with a larger number of patients in oursample, we could also obtain statistical difference in thedata concerning the time of admission, favoring a shorterhospital stay for patients undergoing RMT


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Study Limitation

Unable to perform the RMT in the preoperative period,since the admission had occurred on the eve ofsurgery, precluding condition for the performance ofRMT before surgery.

It is believed that the results would be even moresignificant with the completion of RMT in thepreoperative period.

Another point refers to the loss of patients at

discharge, in the CO group, which may have interferedin any way in the results obtained in our study.


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Conclusion

There is loss of respiratory musclestrengthing patients undergoing CABG

The RMT, performed in the postoperative

period, was effective in restoring thefollowing parameters: MIP, MEP, PEF andtidal volume in this population.


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Thank you


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Threshold IMT

RMT in CABG

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