Effects of Inspiratory Exercise With Linear and Nonlinear Load on Respiratory Variables Post-Bariatric Surgery.

BACKGROUND: Obesity leads to changes in respiratory function, causing reduced lung volumes and mechanical disadvantage of the respiratory muscles. We sought to evaluate the effect of breathing exercises using devices that impose linear and nonlinear load on reversing diaphragm dysfunction and the prevalence of atelectasis after bariatric surgery. METHODS: This was a blind randomized clinical trial. Preoperatively, we assessed the subjects' maximum inspiratory pressure by measuring nasal inspiratory pressure and respiratory muscle endurance with an incremental test based on sustained maximum inspiratory pressure (sustained PImax) and the prevalence of atelectasis by chest radiograph. Subjects were then randomized into 2 groups: a linear load pressure group and nonlinear load pressure group; both groups received conventional respiratory physiotherapy. Subjects were reassessed on the second day after bariatric surgery. RESULTS: We included 40 morbidly obese women (body mass index > 40 kg/m2), age 25-55 years, who underwent bariatric surgery by laparotomy. The groups were homogeneous with respect to age (P = .11), body mass (P = .12), height (P = .75), body mass index (P = .75), nasal inspiratory pressure (P = .48), sustained PImax (P = .89), and absence of atelectasis at baseline. In the reassessment, both groups showed significant reduction in nasal inspiratory pressure (P < .001) and maintenance of sustained PImax (linear load pressure P = .51; nonlinear load pressure P = .055). The prevalence of atelectasis was 15% for linear load pressure and 25% for nonlinear load pressure, with no significant difference between groups (P = .69). CONCLUSION: Both groups were able to maintain respiratory muscle endurance after bariatric surgery. In addition, the treatment contributed to controlling atelectasis so that it did not cause clinical repercussions to the subjects. (ClinicalTrials.gov registration NCT02298517).

Inspiratory loading exercises on respiratory muscle function in post-operative gastroplasty patients: a randomized clinical trial / Exercícios com carga inspiratória na função muscular respiratória no pós-operatório de gastroplastia: um ensaio clínico randomizado / Ejercicios con carga inspiratoria en la función muscular respiratoria en el postoperatorio de gastroplastia: un ensayo clínico aleatorizado

Abstract Introduction: The gastroplasty post-operative period can alter respiratory mechanics and predispose patients to respiratory complications. Objective: The objective was to evaluate the effects of exercises with inspiratory load on respiratory muscle function and on the prevalence of atelectasis after gastroplasty. Method: 40 participants were randomly allocated into two groups: Control Group (CG), its members underwent conventional respiratory physical therapy (CRP) and the Inspiratory Load Group (ILG), its members performed exercises with linear inspiratory pressure load, with 40% of the maximum inspiratory pressure (MIP), associated with CRP. Therapy procedures were conducted twice during the immediate post-operative period and thrice on the first post-operative day. In addition to evaluating the MIP, the nasal inspiratory pressure (NIP) and the sustained maximum inspiratory pressure (SMIP) were evaluated before and after treatment. Analysis of variance followed by the Bonferroni correction were applied considering a 5% significance level (p < 0.05). Results: There was no significant difference in NIP and SMIP values when the pre- and post-operative periods were compared for the ILG; however, these values were significantly lower for the CG, also with intergroup differences in NIP values. Atelectasis prevalence was 5% for ILG and 15% for CG, with no intergroup difference. Conclusion: The inspiratory muscle strength and resistance of the respiratory muscles were maintained in the group that performed exercises with inspiratory load associated with CRP, with a low rate of atelectasis after gastroplasty.

Resumo Introdução: O pós-operatório de gastroplastia pode alterar a mecânica respiratória e predispor a complicações respiratórias. Objetivo: Avaliar os efeitos de exercícios com carga inspiratória na função muscular respiratória e na prevalência de atelectasias após gastroplastia. Método: 40 voluntárias foram alocadas randomicamente em: Grupo Controle (GC), que recebeu Fisioterapia Respiratória Convencional (FRC) e Grupo Carga Inspiratória (GCI), que executou exercícios com carga inspiratória linear pressórica com 40% da pressão inspiratória máxima (PImáx), associados à FRC. Os tratamentos foram realizados duas vezes no pós-operatório imediato e três vezes no primeiro dia pós-operatório. Além da PImáx, foram avaliadas a pressão inspiratória nasal (PIN) e a pressão inspiratória máxima sustentada (PImáxS) antes e após o tratamento. Foi realizada análise de variância seguida de ajuste de Bonferroni, e o nível de significância estatística foi de 5% (p < 0,05). Resultados: Não houve diferença significativa nos valores de PIN e na PImáxS no GCI quando comparados o pré e pós-operatório, diferentemente do GC, no qual esses valores foram significativamente menores além de diferença entre os grupos no valor de PIN. A prevalência de atelectasias foi de 5% para GCI e 15% para GC, sem diferenças intergrupos. Conclusão: Houve manutenção da força muscular inspiratória e da resistência dos músculos respiratórios no grupo que realizou exercícios com carga inspiratória, associado a FRC com baixo índice de atelectasias após gastroplastia.

Resumen Introducción: El postoperatorio de gastroplastia puede alterar la mecánica respiratoria y predisponer a complicaciones respiratorias. Objetivo: Evaluar los efectos de ejercicios con carga inspiratoria en la función muscular respiratoria y en la prevalencia de atelectasias después de la gastroplastia. Método: 40 voluntarias fueron asignadas en: Grupo Control (GC), que recibió Fisioterapia Respiratoria Convencional (FRC) y Grupo Carga Inspiratoria (GCI), que ejecutó ejercicios con carga inspiratoria, realizados con carga lineal inspiratoria con un 40% de la presión inspiratoria máxima (PIM) asociados a la FRC. Ambos tratamientos se realizaron dos veces en el postoperatorio inmediato y tres veces en el primer día postoperatorio. Además de la PIM, se evaluaron la presión inspiratoria nasal (PIN) y la presión inspiratoria máxima sostenida (PImáxS) antes y después del tratamiento. Se realizó el análisis de varianza seguida de ajuste de Bonferroni. Se adoptó nivel de significancia estadística del 5% (p < 0,05). Resultados: No hubo diferencia significativa en los valores de PIN y en la PImáxS en el GCI cuando se compararon en el pre y en postoperatorio, a diferencia del GC, en el cual estos valores fueron significativamente menores más allá de diferencia entre los grupos en el valor de PIN. La prevalencia de atelectasias fue de 5% para GCI y 15% para GC, sin diferencia entre grupos. Conclusión: Hubo mantenimiento de la fuerza muscular inspiratoria y de la resistencia de los músculos respiratorios en el grupo que realizó ejercicios con carga inspiratoria, asociados a la FRC, con bajo índice de atelectasias tras gastroplastia.

Fisioterapia respiratória associada à pressão positiva nas vias aéreas na evolução pós-operatória da cirurgia bariátrica / Respiratory physiotherapy associated with airway positive pressure in the postoperative bariatric surgery evolution

Analisar volume corrente (VC), volume minuto (VM) e frequência respiratória (FR) de obesas mórbidas no pós-operatório de cirurgia bariátrica (CB), após a fisioterapia respiratória convencional (FRC) associada ou não à pressão positiva contínua nas vias aéreas (CPAP) no pré-operatório. Foram estudadas 36 mulheres, com idade de 40,1±8,41 anos, que seriam submetidas à CB por laparotomia e que realizaram FRC (exercícios respiratórios diafragmáticos, de inspirações profundas, fracionadas e associados a movimentos de membros superiores, 1 série de 10 repetições de cada exercício) por 30 dias antes da cirurgia. Após internação, 18 delas foram submetidas a 20 minutos de CPAP, 1 hora antes da indução anestésica e compuseram o grupo FRC+CPAP. As outras 18 não receberam o CPAP e compuseram o grupo FRC. Foram avaliados VM, VC e FR por meio do ventilômetro, no momento da internação e 24 horas após a realização da cirurgia. Constatou-se que as medidas de VC, VM e FR não apresentaram significância estatística quando comparados os resultados do pré e pós-operatório em ambos os grupos, bem como quando comparados os dois grupos entre si tanto no pré como no pós-operatório. Os resultados sugerem que a tanto a aplicação da FRC como a aplicação da FRC+CPAP no período pré-operatório contribui para a manutenção das variáveis respiratórias no pós-operatório. A aplicação do CPAP antes da indução anestésica não promoveu benefícios adicionais no pós-operatório de CB no que se refere aos volumes pulmonares.

To assess the tidal volume (VT), minute volume (MV) and respiratory rate (RR) of morbidly obese women in postoperative bariatric surgery (BS), after the conventional respiratory physiotherapy (CRP) with or without preoperatively continuous positive airway pressure (CPAP). Thirty-six women, aged 40.1±8.41 years, that would be submitted to BS by laparotomy were studied. All of them underwent preoperative outpatient conventional respiratory physiotherapy (CRP) (diaphragmatic breathing exercises, deep breathing, fractionated breathing and breathing associated to movements of the upper limbs, a series of 10 repetitions of each exercise) by 30 days. Once admitted, 18 were subjected to 20 minutes of CPAP, an hour before induction of anesthesia and composed group CRP+CPAP. The other 18 did not receive CPAP and composed group CRP. VT, MV, and RR were performed through the ventilometer, at admission and 24 hours after surgery. It was found that measures of TV, VM and RR were not statistically significant when comparing pre and postoperative in both groups and as well as when the two groups were compared between them in both pre and postoperative. The results suggest that both the application and the implementation of FRC and FRC+CPAP in the preoperative period contribute to the maintenance of respiratory variables in the postoperative period. The use of CPAP before induction of anesthesia, did not provide additional benefits in the post-bariatric surgery with regard to the volumes.

Effects of preoperative inspiratory muscle training in obese women undergoing open bariatric surgery: respiratory muscle strength, lung volumes, and diaphragmatic excursion.

OBJECTIVE: To determine whether preoperative inspiratory muscle training is able to attenuate the impact of surgical trauma on the respiratory muscle strength, in the lung volumes, and diaphragmatic excursion in obese women undergoing open bariatric surgery. DESIGN: Randomized controlled trial. SETTING: Meridional Hospital, Cariacica/ES, Brazil. SUBJECTS: Thirty-two obese women undergoing elective open bariatric surgery were randomly assigned to receive preoperative inspiratory muscle training (inspiratory muscle training group) or usual care (control group). MAIN MEASURES: Respiratory muscle strength (maximal static respiratory pressure--maximal inspiratory pressure and maximal expiratory pressure), lung volumes, and diaphragmatic excursion. RESULTS: After training, there was a significant increase only in the maximal inspiratory pressure in the inspiratory muscle training group. The maximal expiratory pressure, the lung volumes and the diaphragmatic excursion did not show any significant change with training. In the postoperative period there was a significant decrease in maximal inspiratory pressure in both the groups. However, there was a decrease of 28% in the inspiratory muscle training group, whereas it was 47% in the control group. The decrease in maximal expiratory pressure and in lung volumes in the postoperative period was similar between the groups. There was a significant reduction in the measures of diaphragmatic excursion in both the groups. CONCLUSION: The preoperative inspiratory muscle training increased the inspiratory muscle strength (maximal inspiratory pressure) and attenuated the negative postoperative effects of open bariatric surgery in obese women for this variable, though not influencing the lung volumes and the diaphragmatic excursion.

Effects of preoperative inspiratory muscle training in obese women undergoing open bariatric surgery: respiratory muscle strength, lung volumes, and diaphragmatic excursion

OBJECTIVE: To determine whether preoperative inspiratory muscle training is able to attenuate the impact of surgical trauma on the respiratory muscle strength, in the lung volumes, and diaphragmatic excursion in obese women undergoing open bariatric surgery. DESIGN: Randomized controlled trial. SETTING: Meridional Hospital, Cariacica/ES, Brazil. SUBJECTS: Thirty-two obese women undergoing elective open bariatric surgery were randomly assigned to receive preoperative inspiratory muscle training (inspiratory muscle training group) or usual care (control group). MAIN MEASURES: Respiratory muscle strength (maximal static respiratory pressure - maximal inspiratory pressure and maximal expiratory pressure), lung volumes, and diaphragmatic excursion. RESULTS: After training, there was a significant increase only in the maximal inspiratory pressure in the inspiratory muscle training group. The maximal expiratory pressure, the lung volumes and the diaphragmatic excursion did not show any significant change with training. In the postoperative period there was a significant decrease in maximal inspiratory pressure in both the groups. However, there was a decrease of 28 percent in the inspiratory muscle training group, whereas it was 47 percent in the control group. The decrease in maximal expiratory pressure and in lung volumes in the postoperative period was similar between the groups. There was a significant reduction in the measures of diaphragmatic excursion in both the groups. CONCLUSION: The preoperative inspiratory muscle training increased the inspiratory muscle strength (maximal inspiratory pressure) and attenuated the negative postoperative effects of open bariatric surgery in obese women for this variable, though not influencing the lung volumes and the diaphragmatic excursion.

Effects of chest physiotherapy on the respiratory function of postoperative gastroplasty patients.

INTRODUCTION: Bariatric surgery has become increasingly more recommended for the treatment of morbidly obese individuals for whom it is possible to identify co-morbidities other than alterations in pulmonary function. The objective of this study was to evaluate the effects of conventional chest physiotherapy (CCP) and of conventional physiotherapy associated with transcutaneous electrical diaphragmatic stimulation (CCP+TEDS) on pulmonary function and respiratory muscle strength in patients who have undergone Roux-en-Y gastric bypass. METHODS: In total, 44 female patients with an average age of 37 +/- 7.3 years and an average body mass index (BMI) of 47.4 +/- 6.5 K/m(2) were selected as candidates for Roux-en-Y gastric bypass laparoscopy. They were evaluated for pulmonary volume and flow using spirometry and maximum respiratory pressure through manovacuometry during the preoperative period and on the fifteenth and thirtieth postoperative days. RESULTS: No differences were detected between CCP and CCP + TEDS, and both factors contributed to the maintenance of pulmonary flow and volume as well as inhalation muscle strength. Exhalation muscle strength was not maintained in the CCP group at fifteen or thirty days postoperative, but it was maintained in patients treated with conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation. DISCUSSION: These results suggest that both conventional chest physiotherapy and conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation prevent the reduction of pulmonary function during the Roux-en-Y gastric bypass postoperative period, and that transcutaneous electric diaphragmatic stimulation also contributes to expiratory muscle strength.

Comparação entre inspirometria de incentivo e pressão positiva expiratória na função pulmonar após cirurgia bariátrica / Comparison between incentive spirometry and expiratory positive airway pressure on pulmonary function after bariatric surgery

O objetivo deste estudo foi comparar o efeito da pressão positiva expiratória (EPAP, na sigla em inglês) e da inspirometria de incentivo a fluxo sobre a função pulmonar após o bypass gástrico em Y de Roux por ideolaparoscopia. Participaram 28 mulheres, não-tabagistas e não-pneumopatas, com índice de massa corporal entre 35 e 50 kg/m2, submetidas à cirurgia bariátrica. Todas foram avaliadas por espirometria, cirtometria toracoabdominal e quanto à mobilidade diafragmática no pré e segundo dia de pós-operatório (o tempo de internação foi de 2 dias). Foram divididas em dois grupos, GI – grupo inspirômetro (n=13) e GE, grupo EPAP (n=15). A fisioterapia foi iniciada no dia da cirurgia, cada técnica, inspirometria ou EPAP, com duração de 15 minutos; a fisioterapia motora foi padronizada para ambos os grupos. No pós-operatório, houve redução similar nos dois grupos das variáveis: capacidade vital, volume de reserva inspiratório, capacidade vital forçada e ventilação voluntária máxima. Não houve alteração nos valores do volume corrente no GI e volume de reserva expiratório no GE. A mobilidade diafragmática e a mobilidade toracoabdominal foram menos prejudicadas no GI. No pós operatório da cirurgia bariátrica por videolaparoscopia, a inspirometria de incentivo a fluxo exerceu melhores efeitos na manutenção do volume corrente, na mobilidade diafragmática e toracoabdominal, enquanto a EPAP foi mais eficaz no restabelecimento do volume de reserva expiratório...

The aim of this study was to compare the effect of expiratory positive airwaypressure (EPAP) and flow-oriented incentive spirometry on pulmonary function after laparoscopic Roux-en-Y gastric bypass surgery. Twenty-eight non-smoking women, with no lung disease and body mass index of 35 to 50 kg/m2, undergoing laparoscopic gastric bypass surgery (hospitalized for two days) were assessed by spirometry, thoracoabdominal cirtometry and as to diaphragmatic motion prior to, and on the second post-operative day. Before surgery patients were divided into two groups, SG – spirometer group (n=13), and EG – EPAP group (n=15). Motor physical therapy was standardized for both groups; respiratory therapy (both modalities) started on the day of surgery, in 15-minute sessions. Post-operative results showed similar reduction, in both groups, in the values of vital capacity, forced vital capacity, maximum voluntary ventilation, and inspiratory reserve volume. No changes were found in tidal volume values in SG, neither in expiratory reserve volume in EG. Diaphragmatic and thoracoabdominal motion were less harmed in SG. After bariatric surgery thus incentive spirometry had better effect in maintaining tidal volume, as well as on diaphragmatic and thoracoabdominal motion; while EPAP proved more efficient in re-establishing expiratory reserve volume in the postoperative period...

Effects of chest physiotherapy on the respiratory function of postoperative gastroplasty patients

INTRODUCTION: Bariatric surgery has become increasingly more recommended for the treatment of morbidly obese individuals for whom it is possible to identify co-morbidities other than alterations in pulmonary function. The objective of this study was to evaluate the effects of conventional chest physiotherapy (CCP) and of conventional physiotherapy associated with transcutaneous electrical diaphragmatic stimulation (CCP+TEDS) on pulmonary function and respiratory muscle strength in patients who have undergone Roux-en-Y gastric bypass. METHODS: In total, 44 female patients with an average age of 37 ± 7.3 years and an average body mass index (BMI) of 47.4 ± 6.5 K/m² were selected as candidates for Roux-en-Y gastric bypass laparoscopy. They were evaluated for pulmonary volume and flow using spirometry and maximum respiratory pressure through manovacuometry during the preoperative period and on the fifteenth and thirtieth postoperative days. RESULTS: No differences were detected between CCP and CCP+TEDS, and both factors contributed to the maintenance of pulmonary flow and volume as well as inhalation muscle strength. Exhalation muscle strength was not maintained in the CCP group at fifteen or thirty days postoperative, but it was maintained in patients treated with conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation. DISCUSSION: These results suggest that both conventional chest physiotherapy and conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation prevent the reduction of pulmonary function during the Roux-en-Y gastric bypass postoperative period, and that transcutaneous electric diaphragmatic stimulation also contributes to expiratory muscle strength.

Eletroestimulação diafragmática transcutânea em indivíduos saudáveis / Transcutaeous diaphragmatic electrostimulation in healthy individuals

O objetivo deste estudo foi avaliar a influência da EDT na função diafragmática em 20 mulheres jovens e saudáveis, divididas em dois grupos de 10, sendo um controle e outro experimental. A EDT foi realizada com o Phrenix Dualpex, cuja intensidade no grupo controle foi a mínima, para promover sensação de formigamento e no experimental, a suficiente para promover contração visível e palpável do diafragma. Foram avaliadas as medidas de PImax e PEmax, volume corrente (VC), volume minuto (VM), capacidade inspiratória (CI), capacidade vital (CV) e freqüência respiratória (FR), antes e após dez sessões de 30 minutos de EDT. Os resultados no grupo controle não foram significativos. No experimental, os resultados foram significativos para PImax , VC , VM e CI (p < 0,05). Para os valores da PEmax, CV e FR (p > 0,05) não revelaram diferença significativa. Podemos concluir que a EDT se mostrou efetiva na melhora da performance do músculo diafragma desses indivíduos.

The objective of this study was to evaluate the influence of transcutaneous diaphragmatic electrostimulation (TDE) in the function of the diaphragmatic muscle in 20 female young and healthy that were divided into two groups of 10, namely the control group and the study group. The equipment used to apply the TDE was Phoenix Dualpex, and the intensity applied to the control group was just enough to cause a tingling sensation, enough intensity was applied to promote a visible and palpable contraction of the diaphragm. PImax and PEmax, the current volume (CV), minute volume (MV), inspiratory capacity (IC) and vital capacity (VC), the respiratory frequency (RF) before and after ten 30-minute DTE sessions were evaluated. The results in the control group were no statistically significant. To the study group, the results showed a statistically significant difference for PImax , CV, MV and IC (p < 0.05). The PEmax, VC and RF did not show statistically significant differences. We can conclude that TDE was effective in the performance improvement of the diaphragm muscle.