A Comparative Study of IPPB, the Incentive Spirometer, and Blow Bottles: The Prevention of Atelectasis Following Cardiac Surgery

doi:10.1016/S0003-4975(10)63521-7

The Annals of Thoracic Surgery

Volume 25, Issue 3, March 1978, Pages 197-200

https://doi.org/10.1016/S0003-4975(10)63521-7 Get rights and content

Abstract

Following cardiac operations, 145 patients were treated with either intermittent positive-pressure breathing (IPPB), blow 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.

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Cited by (57)

Positive expiratory pressure - Common clinical applications and physiological effects
2015, Respiratory Medicine
Citation Excerpt :
Breathing against an expiratory resistance was first described among patients with chronic obstructive pulmonary disease (COPD) using pursed lips breathing (PLB), controlling the effect with pressure achieved by the lips as the resistance and the effort of the expiration [9,10]. A device for PEP, the ‘blow bottle’, was later introduced [15,16]. The patient exhales through a tube inserted into a bottle of water.
Breathing out against resistance, in order to achieve positive expiratory pressure (PEP), is applied by many patient groups. Pursed lips breathing and a variety of devices can be used to create the resistance giving the increased expiratory pressure. Effects on pulmonary outcomes have been discussed in several publications, but the expected underlying physiology of the effect is seldom discussed.
The aim of this article is to describe the purpose, performance, clinical application and underlying physiology of PEP when it is used to increase lung volumes, decrease hyperinflation or improve airway clearance.
In clinical practice, the instruction how to use an expiratory resistance is of major importance since it varies. Different breathing patterns during PEP increase or reduce expiratory flow, result in movement of EPP centrally or peripherally and can increase or decrease lung volume. It is therefore necessary to give the right instructions to obtain the desired effects. As the different PEP techniques are being used by diverse patient groups it is not possible to give standard instructions. Based on the information given in this article the instructions have to be adjusted to give the optimal effect. There is no consensus regarding optimal treatment frequency and number of cycles included in each treatment session and must also be individualized.
In future research, more precise descriptions are needed about physiological aims and specific instructions of how the treatments have been performed to assure as good treatment quality as possible and to be able to evaluate and compare treatment effects.
Atelectasis as a cause of postoperative fever: Where is the clinical evidence?
2011, Chest
Citation Excerpt :
In this case, the majority of the cases of EPF may be attributed to other causes (eg, perioperative stress), and the rest of them might show temporal association with the emergence of atelectasis. This hypothesis might explain the findings of some of the included studies.27–29 It appears that stress derived by surgery is significant enough to increase the patient's IL-6 levels and thermostatic setpoint.
Atelectasis is considered to be the most common cause of early postoperative fever (EPF) but the existing evidence is contradictory. We sought to determine if atelectasis is associated with EPF by analyzing the relevant published evidence.
We performed a systematic search in PubMed and Scopus databases to identify studies examining the association between atelectasis and EPF.
A total of eight studies, including 998 cardiac, abdominal, and maxillofacial surgery patients, were eligible for analysis. Only two studies specifically examined our question, and six additional articles reported sufficient data to be included. Only one study reported a significant association between postoperative atelectasis and fever, whereas the remaining studies indicated no such association. The performance of EPF as a diagnostic test for atelectasis was also assessed, and EPF performed poorly (pooled diagnostic OR, 1.40; 95% CI, 0.92-2.12). The significant heterogeneity among the studies precluded a formal metaanalysis.
The available evidence regarding the association of atelectasis and fever is scarce. We found no clinical evidence supporting the concept that atelectasis is associated with EPF. More so, there is no clear evidence that atelectasis causes fever at all. Large studies are needed to precisely evaluate the contribution of atelectasis in EPF.
The physiotherapy management of patients undergoing coronary artery surgery: A questionnaire survey
1996, Australian Journal of Physiotherapy
The current physiotherapy management of patients undergoing coronary artery surgery in 22 public and 13 private hospitals across Australia and New Zealand was examined using a questionnaire survey. Respondents were asked to identify assessment and treatment techniques used in the pre-and post-operative management. An 83 per cent response from physiotherapists was obtained. Ninety-four per cent of respondents reported that pre-operative assessment was performed routinely. Eighty-nine per cent of respondents indicated that all patients were treated routinely by physiotherapists in the post-extubation period. Positioning and deep breathing exercises were the most commonly used techniques for patients post-extubation. Factors determining treatment choice and the impact of research on current physiotherapy practice are discussed.
Prevention of respiratory complications after abdominal surgery
1996, Annales Francaises d'Anesthesie et de Reanimation
La chirurgie abdominale altère la fonction respiratoire, et les complications pulmonaires sont une des premières causes de morbidité et de mortalité postopératoires. Après une analyse de l'incidence et des facteurs de risque des complications respiratoires, cette revue de la littérature examine les moyens de leur prévention et de leur traitement. L'évaluation préopératoire est surtout clinique et les épreuves fonctionnelles respiratoires (EFR) ne sont pas indispensables. La prédiction des complications est difficile. Certains risques comme l'âge ou le type de chirurgie sont inévitables. Souvent le temps de préparation est trop court pour améliorer l'état nutritionnel. Mais les désordres métaboliques doivent être corrigés et la consommation de tabac arrêtée 8 semaines avant l'intervention pour obtenir un réel bénéfice. Pour les patients atteints de bronchopneumopathie chronique obstructive (BPCO), l'évaluation sera faite, si nécessaire, par le pneumologue, le kinésithérapeute, le chirurgien et l'anesthésiste. En l'absence d'examen préalable, des EFR avec examen des gaz du sang seront faites pour quantifier le trouble et évaluer les effets d'un traitement. Un patient ne devrait pas être récusé sur des critères spirométriques. La préparation, débutée au moins 24 à 48 heures avant l'intervention, comprend des antibiotiques, des bêta-2-agonistes, des anticholinergiques en aérosol, voire de la théophylline et de la kinésithérapie respiratoire. Le traitement doit continuer 3 à 5 jours en phase postopératoire. En règle générale, l'anesthésie entraîne des complications précoces, et la chirurgie des complications tardives. Les interventions par voie de cœlioscopie permettent de diminuer la morbidité postopératoire, surtout chez les patients sans antécédent respiratoire. Il n'a pas été démontré que l'anesthésie locorégionale, ou une technique particulière d'analgésie postopératoire étaient capables de diminuer les complications respiratoires. Après l'intervention, l'oxygène améliore la SaO₂ mais ne prévient pas les épisodes de désaturation dus aux apnées obstructives. Les différentes techniques de kinésithérapie sont équivalentes, mais la ventilation artificielle à pression positive intermittente donne lieu à de sérieux effets secondaires et doit être abandonnée. La kinésithérapie et la spirométrie incitative sont simples, non invasives et indiquées pour traiter l'encombrement bronchique et les atélectasies. La respiration en pression positive continue est efficace contre les atélectasies. Pour les patients atteints de BPCO (stade II ou III), une prise en charge en milieu de soins intensifs et une ventilation mécanique prolongée sont parfois nécessaires.
Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO₂, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.
The effect of physical therapy on respiratory complications following cardiac valve surgery
1996, Chest
To determine whether higher personnel intensive chest physical therapy can prevent the atelectasis that routinely follows cardiac valve surgery.
Randomized, controlled trial.
Tertiary care hospital.
Seventy-eight patients undergoing elective cardiac valve surgery between October 1991 and April 1993 were enrolled.
Patients were randomized 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-handed percussions (higher-intensity treatment).
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.
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.
Postoperative atelectasis and pneumonia
1995, Heart and Lung - The Journal of Acute and Critical Care
Postoperative pulmonary complications, specifically atelectasis and pneumonia, are the leading cause of postoperative morbidity and death. It is crucial that the clinician have a thorough understanding of the pathophysiology, risk factors, and scientific basis for currently used respiratory interventions to tailor the patient's care in the preoperative, intraoperative, and postoperative settings. Given the changing healthcare environment and increasing economic constraints, all respiratory interventions must be reevaluated for use in patient care, keeping in mind the factors of scientific basis, patient needs, appropriate utilization, and quality patient outcomes.

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: We wish to acknowledge the assistance of Prof. David R. Brillinger, University of California, Berkeley, who provided the statistical analysis of our data.

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A Comparative Study of IPPB, the Incentive Spirometer, and Blow Bottles: The Prevention of Atelectasis Following Cardiac Surgery

Abstract

Am J Surg

J Thorac Cardiovasc Surg

Lancet

Dis Chest

A rebreather for prophylaxis and treatment of postoperative respiratory complications

Dis Chest

Prevention of post-operative pulmonary complications

JAMA

Respiratory maneuvers to prevent post-operative pulmonary complications

JAMA

An evaluation of IPPB in the prevention of post-operative pulmonary complications

Arch Surg