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ORIGINAL ARTICLE
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 353-358

Evaluation of two different respiratory physiotherapy methods after thoracoscopy with regard to arterial blood gas, respiratory function test, number of days until discharge, cost analysis, comfort and pain control


1 Department of Thoracic Surgery, Harran University Faculty of Medicine, Sanliurfa, Turkey
2 Department of Public Health, Harran University Faculty of Medicine, Sanliurfa, Turkey

Date of Acceptance01-Sep-2015
Date of Web Publication28-Mar-2016

Correspondence Address:
Dr. S Gunay
Department of Thoracic Surgery, Harran University Faculty of Medicine, Sanliurfa
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.179279

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   Abstract 

Introduction: Although the methods used in thoracic surgery have been developing rapidly over the last five decades, postoperative pulmonary complications are seen in this field more than in other surgical branches. We aimed at comparing the acute effects of incentive spirometry (IS) and breathing retraining exercises by a respiratory physiotherapist or experienced physiotherapist.
Methods: Patients were randomized into two groups as spirometry and physiotherapist. Combined respiratory exercises were implemented through IS inspirometry group and by a physiotherapist in physiotherapist group. Blood gas, respiratory function tests, survey results of the Burford pain thermometer, discharge days, and cost analyses of both groups were examined just before the beginning of physiotherapy and on the 3rd day of therapy.
Results: There were no statistical difference in first and last values of pH and PCO2and also there were no difference between groups (P > 0.05). Forced expiratory volume one second (FEV1) values are statistically increased compared to basal levels in both groups and mean difference in FEV1values was statistically increased in physiotherapist group compared to spirometry group (P < 0.001). Forced vital capacity (FVC), PO2and SaO2 values are statistically increased compared to basal levels in both groups but mean difference in FVC values was not statistically different between groups (P > 0.05). Cost analysis was not statistically different, mean hospitalization day and mean pain score were statistically decreased in physiotherapist group.
Conclusions: Based on the outcome of this study, respiratory physiotherapy methods carried out by a respiratory physiotherapist are more effective in acute cardiothoracic conditions after thoracotomy compared to IS by patients.

Keywords: Incentive spirometry, postoperative complications, respiratory physiotherapy


How to cite this article:
Gunay S, Eser I, Ozbey M, Agar M, Koruk I, Kurkcuoglu I C. Evaluation of two different respiratory physiotherapy methods after thoracoscopy with regard to arterial blood gas, respiratory function test, number of days until discharge, cost analysis, comfort and pain control. Niger J Clin Pract 2016;19:353-8

How to cite this URL:
Gunay S, Eser I, Ozbey M, Agar M, Koruk I, Kurkcuoglu I C. Evaluation of two different respiratory physiotherapy methods after thoracoscopy with regard to arterial blood gas, respiratory function test, number of days until discharge, cost analysis, comfort and pain control. Niger J Clin Pract [serial online] 2016 [cited 2021 Aug 5];19:353-8. Available from: https://www.njcponline.com/text.asp?2016/19/3/353/179279


   Introduction Top


Since being implemented in thoracic surgery, thoracotomy and video-assisted thoracoscopic surgery methods have progressed rapidly over the last five decades.[1],[2],[3] Diagnosis and treatment techniques change constantly, especially for pleural effusions, which is a subject dealt with frequently in chest disease and thoracic surgery, and diagnostic potential increases with each passing day.[4] Diagnosis percentages of pleural effusions through thoracentesis and/or closed pleural biopsy are 25% and 60%, respectively, and as is seen, these methods have a very low diagnosis potential.[4],[5] Thoracoscopyis both a reliable and easy method to use for diagnosing and treating pleural effusions. The use of thoracoscopy by an experienced physician increases both the diagnosis percentage and the surgeon's reliability. Especially the incidence of postoperative pulmonary complications after thoracic surgery is greater compared to other surgeries.[6],[7] Pulmonary complications continue to be the most frequent cause of postoperative death, and they are the most frightening and unwanted complications for surgeons.[8] Although there are many postoperative complications that are seen, the highest mortality is with pulmonary complications. These complications include atelectasis, consolidation, pleural effusion, permanent air leakage, and pneumonia.[6],[7],[8] Another frequently seen postoperative complication is a pain. Insufficient coughing, limitation of movement and insufficient breathing develop in cases of pain that cannot be brought under control, and mortality may increase through pulmonary and cardiac complications that are seen in such cases.[9]

It is emphasized that operation time and method, age, weight, smoking, skeletal deformities and the existence of pulmonary disease are associated with the prevalence of these complications in the studies carried out on this topic in particular.[8],[9]

Methods developed for preventing these complications are preoperative walking, active intervention and incentive spirometry (IS) for strengthening breathing muscles, percussion, vibration, postural drainage, effective coughing and early mobilization. Implementation of these suggestions by a competent and physiotherapist increases their efficiency.[8],[9],[10],[11],[12]

There have been only a few research studies analyzing the physiotherapeutic methods used in patients undergoing thoracic surgery, and efficiency of pain control, shoulder mobilization exercise, and extensive postoperative physiotherapeutic intervention were reported from these studies.[1],[2],[3] In some studies, it was emphasized that the physiotherapy implemented after major surgery was unneeded and increased costs.[13],[14],[15],[16]

Comparative studies that analyze the acute effects of different chest physiotherapy methods after thoracic surgery operations on arterial blood gas (ABG) and respiratory function are rarely seen in the literature. Therefore, we wanted to report on the effects of thoracoscopy and tube thoracostomy methods, which are the most frequently used methods in thoracic surgery, on ABG and respiratory function of patients by implementing breathing exercises through IS and physiotherapy (P), which are two methods of chest physiotherapy in the early postoperative period, together with a cost analysis comparison, pain and satisfaction comparisons and discharge time comparisons in relation to the literature.


   Methods Top


The Institutional Ethical Committee approved this study, which was performed in accordance with the ethical principles for human investigations as outlined by the Second Declaration of Helsinki.

Fifty patients with pleural effusion, who were hospitalized between the dates of March 2013 and March 2014 and implemented thoracoscopy included in this study. Patients underwent thoracoscopy with pleural sampling and who did not have atelectasia and postoperative air leakage, with expanded chest radiography after postoperative 24 h, were included in the study. Patients with additional pathologies such as rib fracture, with air leakage and also implemented parenchymal sampling were excluded from the study. Fifty consecutive patients who met the inclusion criteria stated above were randomly chosen into two groups. Respiratory physiotherapy with only the IS was implemented to the spirometry ( first) group patients after being taught by physiotherapist; and diaphragm respiration, costal respiration exercises, efficient coughing, posture exercises and combined respiration exercises were supervised or carried out by respiratory or experienced cardiopulmonary physiotherapist for thirty minutes and two times a day to the physiotherapist (second) group.

Respiration physiotherapies were initiated in both groups after seeing that the lungs were expanded by evaluation of chest radiographies 24 h postoperatively. Blood gases were taken from both patient groups just before the start of physiotherapy and on the 3rd day of physiotherapy, and their pulmonary function tests (PFT) were checked. Alterations in the pH, PO2, PCO2 and SPO2 values in the ABG of the patients and in the forced expiratory volume one second (FEV1) and forced vital capacity (FVC) values in the PFT were evaluated. In addition, information such as on which day patients were discharged, cost data and findings of the Burford pain thermometer [17] survey, which was implemented on the postoperative 1st and 3rd days for each patient, were evaluated. Use of the Burford pain thermometer is currently not common in our country. This scale involves clear-cut verbal expressions combined with numbers: 0–1 defines painlessness, 2–3 dull, 4–5 disturbing, 6–7 acute, 8–9 extreme severity, and 10 insufferable pain. Pain and satisfaction were evaluated with this survey between the two groups.

Statistical methods

Statistical Package for the Social Sciences (SPSS) 21 (IBM Corporation, Armonk, New York, United States) and PAST programs were used in data analysis. The conformity of univariate data to normal distribution was analyzed with the Kolmogorov–Smirnov test, Shapiro–Wilk test and variation coefficients, and the conformity of multivariate data to normal distribution was analyzed using Mardia, and Doornik Omnibus test. Parametric methods were used in the analysis of variables with normal distribution, and nonparametric methods were used in the analysis of variables without normal distribution. Independent-samples t and Mann–Whitney U (Exact) tests were used in the comparison of two independent groups. Paired-samples t and Wilcoxon Signed Ranks tests were used for twice repetitive measurement of dependent variables and general linear model-repeated ANOVA tests were used for analyzing the interaction of the repetitive measurements of variables according to groups. The comparison of categorical data was measured through Pearson Chi-square (exact) test. Quantitative data are expressed as mean ± standard deviation and median ± Interquartile Range values in the tables. Categorical data are expressed as number and percentages. Data were analyzed at 95% confidence level, and P value was regarded as significant if it was smaller than 0.05.


   Results Top


A total of 25 patients, 18 (72%) males and 7 (28%) females, with an age average of 49.20 ± 12.22 were in the group IS. Six (24%) of these patients were smokers, whereas 19%76%) were nonsmokers [Table 1]. A total of 25 patients, 18 (72%) males and 7 (28%) females, with an age average of 51.20 ± 12.22 were in the group P. Again, 6 (24%) of these patients were smokers, whereas 19%76%) were nonsmokers [Table 1]. It was determined that both groups were homogeneous, and there was not any significant difference between them statistically (P > 0.05). As shown in [Table 1], there was no difference between the two groups with regard to smoking, which is one of the most frequent reasons for postoperative respiratory complications and increases this complication 6-fold (P > 0.05).[18]
Table 1: Intergroup age, gender and smoking

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As shown in [Table 2], after comparing FEV1, FVC, pH, PO2, PCO2, and SPO2 values were compared in themselves as the first and last values; both groups were compared between each other. A statistically significant increase was determined in the FEV1 and FVC values in the IS intragroup PFT parameters (P < 0.001). A statistically significant increase was determined in the PO2 and SPO2 values in the IS intragroup ABG parameters (P < 0.001), when it was not determined a statistically significant change in the pH (P = 0.144) and PCO2 (P = 0.414) values [Table 2]. There was a statistically significant increase in the FEV1 and FVC values in theP intragroup PFT parameters (P < 0.001). A statistically significant increase was determined in the PO2, SPO2 values in the IS intragroup ABG parameters (P < 0.001), when it was not determined a statistically significant change in the pH (P = 0.268) and PCO2 (P = 0.954) values [Table 2]. A statistically significant difference emerges between the two groups only with regards to the increase in the FEV1 value in the comparison of IS andPgroups (P < 0.05) [Figure 1], when it was not determined a statistical significance difference between the two groups in the alterations of FVC, pH, PO2, PCO2 and SPO2 values (P > 0.05).
Table 2: FEV1, FVC, pH, PO2, PCO2, SPO2 changes of data

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Figure 1: FEV1 changes between IS and PP

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We see that only FEV1 value changes were significant in the comparison of the IS and PP groups (P < 0.05) [Figure 1]. There was no difference between the two groups with regard to changes in FVC, pH, PO2, PCO2 and SPO2 values (P > 0.05).

The cost analysis, the average discharge day and Burford pain thermometer values of two groups were compared in [Table 3]. When the average cost analysis of the group IS was 437.87 € ±83.45 €, the average cost analysis of the group P was determined as 464.43 € ±86.43 €. A statistically significant difference was not determined between two groups in terms of the cost analysis (P > 0.005). When the patients in the group IS were discharged in 10.12 ± 3.34 days on the average, the patients in the group P was discharged in 8.63 ± 3.86 days on the average. In the comparison of the discharge day numbers of patients, it was statistically determined that the patients in group P were discharged earlier (P < 0.001). The Burford pain thermometer survey averages performed on the IS patient group were determined as 4.1 ± 1.35 on the postoperative 1st day and as 7.4 ± 2.87 on the postoperative 3rd day. The Burford pain thermometer survey averages performed on theP patient group were determined as 4.4 ± 2.1 on the postoperative 1st day and as 8.6 ± 2.64 on the postoperative 3rd day. Based on the Burford pain thermometer survey results of both groups, it was determined that the group P felt lesser pain with a statistically significant difference (P < 0.005).
Table 3: Cost, satisfaction and number of days until discharge for IS and PP groups

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   Discussion Top


In the last five decades, thoracic surgery has seen major developments in minimally invasive techniques. Accordingly, there have been decreases in complications and mortality experienced in thoracic surgery, and measures have been taken against these complications. We can include respiratory physiotherapy among the measures to decrease postoperative pulmonary complications. Although intensive work has been carried out in postoperative respiratory physiotherapy in other large surgical groups, there are very few literature reports that analyze respiratory physiotherapy after thoracic surgery.[1],[2],[3],[8]

Besides the disorders observed in respiratory function after surgery and anesthesia, the rarity of secretion excretion increases the complication incidence as well.[8],[9],[19],[20] Therefore, scholars have researched the effects of different chest physiotherapy methods on the incidence of complications in order to prevent pulmonary complications.[8] In work carried out with IS, Gosselink et al. showed that this provided additional benefit in decreasing postoperative pulmonary complications in patients who underwent thoracic surgery.[21] We also deemed the use of IS to be suitable as an efficient physiotherapy method alternative for group PP.

In our study, we determined that there was a difference between the IS and PP groups only for changes in FEV1 values. Pulmonary function tests is the most frequently used method in the diagnosis and treatment of respiratory diseases for determining the severity and for following the course of the disease. The most frequently used parameter in follow-up with this method is FEV1. FEV1 is the amount of air emitted in the first second. A change in FEV1 is evidence indicating that the patient breathes more comfortably, and accordingly, the PP method is more efficient than IS.

In addition, it is possible to prevent and diagnose postoperative complications early with the training of nurses and allied health personnel.[1] In our study, we faced the same situation and found that we obtained more advantageous results with the personnel we trained before the study.

In some studies carried out on postoperative physiotherapy intervention, the role of preoperative physiotherapy in patients undergoing a major operation, including thoracic surgery, could not be completely understood.[22],[23] In their study, Stigt et al. determined that they could not provide better life quality with rehabilitation carried out after Adjuvan KT.[24] In spite of partially supporting these theories, our results could not determine differences in some parameters measured in our study. Among these parameters were FVC, pH, PO2, PCO2 and SPO2 values. In a study by Nagarajan et al., they found a significant recovery in FVC values with physiotherapy of patients who underwent pulmonary resection and proved that the exercise capacity of patients with major thoracic surgery increased.[25] However, it is known that changes in FVC, which is defined as the air breathed out from the lungs during the compelling expiratory maneuver, and ABG, occur after a long period. Since our study was short-term, we did not find any changes in these values. When we examined our research retrospectively, we think that we could have obtained different results if we had repeated the same measurements in the postoperative 1st month. Again, in the cost analysis performed by Nagarajan et al., they showed a decrease in general treatment expenditures in the physiotherapy group.[25] In our study, we could not determine a difference between the two groups with regard to cost (P > 0.005). However, although the early discharge of the group implementing PP resulted in decreased expenditures, a difference was not determined between the two groups when adding the charge paid to physiotherapist, who dealt with the patients, to the total cost. More importantly than all these values, patient comfort, pain control and satisfaction were clearly higher in patients implementing PP.


   Conclusions Top


Based on the outcome of this study, respiratory physiotherapy methods carried out by a respiratory physiotherapist is more effective in acute cardiothoracic conditions after thoracotomy compared to IS by patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Seber M, Gurses HN, Bayındır O, Guzelsoy D, Orbay B, Aytaç A, et al. A comparison of two different chest phtsiotherapy thechniques in the early post operative stageafetr open heart surgery. Physiother Rehabil 1994;7:44-53.  Back to cited text no. 8
    
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Mackay MR, Ellis E, Johnston C. Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Aust J Physiother 2005;51:151-9.  Back to cited text no. 16
    
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Bachiocco V, Morselli AM, Carli G. Self-control expectancy and postsurgical pain: Relationships to previous pain, behavior in past pain, familial pain tolerance models, and personality. J Pain Symptom Manage 1993;8:205-14.  Back to cited text no. 17
    
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Reid JC, Jamieson A, Bond J, Versi BM, Nagar A, Ng BH, et al. A pilot study of the incidence of post-thoracotomy pulmonary complications and the effectiveness of pre-thoracotomy physiotherapy patient education. Physiother Can 2010 Winter;62(1):66-74.  Back to cited text no. 18
    
19.
Morano MT, Araújo AS, Nascimento FB, da Silva GF, Mesquita R, Pinto JS, et al. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: A pilot randomized controlled trial. Arch Phys Med Rehabil 2013;94:53-8.  Back to cited text no. 19
    
20.
Fernandez MA. Additional thoughts on 'does the addition of deep breathing exercises to physiotherapy-directed mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial'. Physiotherapy 2014;100:275.  Back to cited text no. 20
    
21.
Gosselink R, Schrever K, Cops P, Witvrouwen H, De Leyn P, Troosters T, et al. Incentive spirometry does not enhance recovery after thoracic surgery. Crit Care Med 2000;28:679-83.  Back to cited text no. 21
    
22.
Mackay M, Ellis E. Physiotherapy out comes and staffing resources in open abdominal surgery patients. Physiother Theory Pract 2002;18:75-93.  Back to cited text no. 22
    
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Reeve J, Ewan S. The physiotherapy management of the coronary artery bypass graft patient: A survey of current practice through out the United Kingdom. J Assoc Chart Physiotherapists in Respir Care 2005;37:35-45.  Back to cited text no. 23
    
24.
Stigt JA, Uil SM, van Riesen SJ, Simons FJ, Denekamp M, Shahin GM, et al. A randomized controlled trial of postthoracotomy pulmonary rehabilitation in patients with resectable lung cancer. J Thorac Oncol 2013;8:214-21.  Back to cited text no. 24
    
25.
Nagarajan K, Bennett A, Agostini P, Naidu B. Is preoperative physiotherapy/pulmonary rehabilitation beneficial in lung resection patients? Interact Cardiovasc Thorac Surg 2011;13(3):300-2.  Back to cited text no. 25
    


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  [Table 1], [Table 2], [Table 3]


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