Breathing Training Benefits Heart-Surgery Patients

It helped reduce pulmonary complications, such as pneumonia, study finds

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By Amanda Gardner
HealthDay Reporter

TUESDAY, Oct. 17, 2006 (HealthDay News) -- Modern medicine is turning to life's simplest and most essential activity to help heart-surgery patients: breathing.

Patients undergoing coronary artery bypass graft (CABG) who are at high risk for pulmonary complications, such as pneumonia, reduced that risk by performing breathing exercises and receiving respiratory muscle training before surgery.

"We found that preventive physical therapy given to patients at high risk of postoperative pulmonary complications before CABG surgery decreased the incidence of atelectasis [collapse of the lung] and pneumonia significantly, and shortened the duration of mechanical ventilation and postoperative hospitalization," said Erik Hulzebos, a doctoral candidate, clinical exercise physiologist and sports physiotherapist at University Medical Center Utrecht, in the Netherlands.

"We [and other studies] demonstrated that our program is safe and well-tolerated and should be implemented in regular care for these patients as soon as possible," Hulzebos continued.

Others agreed.

"It is a well done paper with a very simple maneuver that may have a significant impact because it does three things," said Dr. Alejandro C. Arroliga, director of the division of pulmonary/critical care medicine at Scott & White Hospital, part of Texas A&M Health Science Center College of Medicine. "It improves muscle function, and this improvement translates into a well-defined benefit [reduction in pneumonia] and the effect was better in smokers than in non-smokers, so it is worth doing."

But it might mean that surgery would have to be delayed.

"The value of the article is that there are people you can identify that maybe it would be worth to put surgery off for a little while," said Dr. Wade Knight, associate professor of surgery at Texas A&M Health Science Center College of Medicine. "It's better to have patients off the breathing machine and out of the hospital. Doctors just have to make a clinical judgment about waiting."

Despite improvements in the way coronary artery bypass surgery is performed, the rate of post-surgery lung complications has remained steady, possibly because CABG can now be done on more high-risk patients.

The authors of the new study, published in the Oct. 18 issue of the Journal of the American Medical Association, wanted to see if the pre-hospitalization period could be used to improve patients' lung conditions and thereby reduce the rate of post-surgery problems.

The study involved 279 patients undergoing elective CABG surgery at University Medical Center Utrecht. The patients, all of whom were at high risk for postoperative pulmonary complications, were randomly assigned to receive either preoperative inspiratory (breathing in) muscle training or regular care.

The muscle training involved individualized exercises that were performed seven times a week for at least two weeks before the operation. Participants also received instruction in breathing techniques, and spirometry was used to measure lung capacity.

Participants in the muscle-training group experienced 48 percent fewer complications than those in the usual care group (18 percent vs. 35 percent, respectively). They also needed less mechanical ventilation than the usual-care group.

In the muscle-training group, 6.5 percent of patients developed pneumonia, compared to 16.1 percent in the usual care group, a reduction of 60 percent. And, the median hospital stay following surgery was seven days for the muscle-training group and eight days for the usual care group.

The study also showed that it was possible to stratify patients before surgery, based on their risk of developing post-surgery pulmonary complications, Hulzebos said.

Interestingly, the patients who turned out to be high risk may not, at first glance, have looked that way.

"When they talk of being overweight, and they give a BMI [body mass index] of 27, this is not even obese. This is slightly overweight. And there was only mild to moderate pulmonary dysfunction," said Dr. Hormoz Ashtyani, director of pulmonary critical care and sleep medicine at Hackensack University Medical Center in Hackensack, N.J. "To incorporate this into actual practice, we need to increase awareness of assessing certain risks that otherwise would be considered mild. These patients did not stand out as high risk. They were not huffing and puffing with emphysema or morbidly obese," Ashtyani added.

Ultimately, the most effective part of the pre-surgery breathing training may have been the doctor-patient interaction.

"I think that most things in medicine that don't work are due to the lack of education," Arroliga said. "The time that was spent with the patient is a way of feeding back to the patient the importance of these things."

More information

Visit the American Lung Association for more on lung function.

SOURCES: Erik H. J. Hulzebos, P.T., M.Sc., clinical exercise physiologist and sports physiotherapist, University Medical Center and Children's Hospital, Utrecht, the Netherlands; Hormoz Ashtyani, M.D., director, pulmonary critical care and sleep medicine, Hackensack University Medical Center, Hackensack, N.J.; Alejandro C. Arroliga, M.D., director, division of pulmonary/critical care medicine, Scott & White Hospital, affiliated with Texas A&M Health Science Center College of Medicine; Wade Knight, M.D., associate professor of surgery, Texas A&M Health Science Center College of Medicine, and cardiothoracic surgeon at Scott & White Hospital, Temple, Texas; Oct. 18, 2006, Journal of the American Medical Association

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