Do directed cough maneuvers improve cough effectiveness in the early period after open heart surgery? Effect of thoracic support and maximal inspiration on cough peak expiratory flow, cough expiratory volume, and thoracic pain.

BACKGROUND: Directed cough maneuvers are often included in physiotherapy management aimed at preventing postoperative pulmonary complications after open heart surgery, but there is little scientific evidence of the effectiveness of directed cough maneuvers. METHODS: We conducted a randomized intra-subject crossover trial to evaluate the effect of thoracic support (patient holds his or her hands over the incision) and maximal inspiration on cough peak expiratory flow (CPEF), cough expiratory volume (CEV), and incision pain during cough in the early period after open heart surgery. Cough evaluation was undertaken on the first and second morning after surgery. On both measurement days the subject did a baseline cough (baseline cough 1) then, in a random sequence, performed 3 cough conditions: an additional baseline cough (baseline cough 2), supported cough, and supported cough preceded by maximal inspiration. In these test conditions a P < .008 was deemed to indicate a statistically significant difference. RESULTS: Twenty-one subjects participated. Thoracic support alone did not significantly affect CPEF or CEV (Bonferroni adjusted P > .008). With a maximal inspiration and thoracic support, CPEF and CPEV were significantly higher than in all other cough conditions (Bonferroni adjusted P < .008). Pain during cough was not influenced by the different cough conditions (P > .05). There was no significant difference in the cough variables or pain during the different cough conditions on the first day versus the second measurement day. CONCLUSIONS: Maximal inspiration increased CPEF and CEV, but the method of thoracic support we used did not reduce pain during cough or influence the cough values we measured.

Pleurotomy with subxyphoid pleural drain affords similar effects to pleural integrity in pulmonary function after off-pump coronary artery bypass graft.

BACKGROUND: Exacerbation of pulmonary dysfunction has been reported in patients receiving a pleural drain inserted through the intercostal space in comparison to patients with an intact pleura undergoing coronary artery bypass grafting (CABG). Evidence suggests that shifting the site of pleural drain insertion to the subxyphoid position minimizes chest wall trauma and preserves respiratory function in the early postoperative period. The aim of this study was to compare the pulmonary function parameters, clinical outcomes, and pain score between patients undergoing pleurotomy with pleural drain placed in the subxyphoid position and patients with intact pleural cavity after off-pump CABG (OPCAB) using left internal thoracic artery (LITA). METHODS: Seventy-one patients were allocated into two groups: I (n = 38 open left pleural cavity and pleural drain inserted in the subxyphoid position); II (n = 33 intact pleural cavity). Pulmonary function tests and clinical parameters were recorded preoperatively and on postoperative days (POD) 1, 3 and 5. Arterial blood gas analysis and shunt fraction were evaluated preoperatively and in POD1. Pain score was assessed on POD1. To monitor pleural effusion and atelectasis chest radiography was performed routinely 1 day before operation and until POD5. RESULTS: In both groups a significant impairment was found in lung function parameters until on POD5. However, no significant difference in forced vital capacity and forced expiratory volume in 1 second were seen between groups. A significant decrease in partial pressure of arterial oxygen and an increase in shunt fraction values were observed on POD1 in both groups, but no statistical difference was found when the groups were compared. Pleural effusion and atelectasis until on POD5 were similar in both groups. There were no statistical differences in pain score, duration of mechanical ventilation and postoperative hospital stay between groups. CONCLUSION: Subxyphoid insertion of pleural drain provides similar effects to preserved pleural integrity in pulmonary function, clinical outcomes, and thoracic pain after OPCAB. Therefore, our results support the hypothesis that once pleural cavities are incidentally or purposely opened during LITA dissection, subxyphoid placement of the pleural drain is recommended.

Endotracheal tube cuff pressure assessment maneuver induces drop of expired tidal volume in the postoperative of coronary artery bypass grafting.

BACKGROUND: Previous investigations reported that the cuff pressure (CP) can decrease secondary to the CP evaluation itself. However is not established in literature if this loss of CP is able to generate alterations on expired tidal volume (ETV). Therefore, the aim of this study was to evaluate the potential consequences of the endotracheal CP assessment maneuver on CP levels and ETV in the early postoperative of coronary artery bypass grafting (CABG). METHODS: A total of 488 patients were analyzed. After the operation, the lungs were ventilated in pressure-assist-control mode and the same ventilatory settings were adjusted for all patients. After intensive care unit arrival, the cuff was fully deflated and then progressively inflated by air injection, to promote a minimal volume to occlude the trachea. To assist the cuff inflation and the air leakage identification, the graphical monitoring of the volume-time curve was adopted. After 20 minutes a first cuff pressure evaluation was performed (P1) and a second measurement (P2) was taken after 20 minutes with an analog manometer. ETV was obtained always pre and post P1 measurement. RESULTS: The CP assessment maneuver promoted a significant drop of P2 in relation to P1 when the manometer was attached to the pilot balloon (p < 0.0001). When compared the moments, pre-P1 versus post-P1, a significant drop of the ETV was also observed (p < 0.0001). CONCLUSION: The CP assessment maneuver promoted a significant decrease in CP values and occurrence of air leakage with reduction of ETV in the early postoperative of CABG.

Ministernotomy in myocardial revascularization preserves postoperative pulmonary function.

BACKGROUND: In coronary artery bypass graft (CABG) surgery, the need to perform a midsternotomy has been considered a factor for the decrease in postoperative pulmonary function. OBJECTIVE: To prospectively evaluate early postoperative (PO) pulmonary function in patients submitted to off-pump CABG, comparing the conventional midsternotomy with the ministernotomy approach. METHODS: A total of 18 patients were evaluated and assigned to the two groups: Group Conventional Midsternotomy (CMS, n=10) and Group Ministernotomy (MS, n=8). Spirometric results of the forced vital capacity (FVC) and the Forced Expiratory Volume in one second (FEV1) were obtained on the 1st, 3rd and 5th PO days and the arterial gasometry was obtained before and on the 1st PO day. The pulmonary shunt percentage and the pain score were also assessed. RESULTS: When compared in terms of percentage of the preoperative value, the FVC was higher in the MS group than in the CMS group on the 1st, 3rd and 5th PO days (p<0.001). Similar results were obtained for FEV1. The recovery of the FVC between the 1st and the 5th PO days was higher in the MS than in the CMS group (p=0,043). The PaO2 decreased on the 1st PO day in both groups (p<0.05), with a higher decrease in the CMS group (p=0.002). The shunt increased in the two groups on the 1st PO day (p<0.05); however, it was lower in the MS group (p=0.02). The reported pain score was lower and the duration of the hospital stay was shorter in the MS group. CONCLUSION: Patients submitted to CABG by MS present better preservation and recovery of pulmonary function than those submitted to CMS.

Influence of pleurotomy on pulmonary function after off-pump coronary artery bypass grafting.

BACKGROUND: This study evaluated the influence of pleurotomy on pulmonary function after off-pump coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA). METHODS: Thirty patients were prospectively allocated into two groups: 15 patients with an opened left pleural cavity (OP group) and 15 patients with an intact pleural cavity (IP group). Bedside pulmonary function tests were recorded preoperatively and on postoperative days 1, 3, and 5. Arterial blood gas analyses and ratio of partial pressure of arterial oxygen (PaO2/fraction of inspired oxygen (FiO2) ratio were evaluated preoperatively and on postoperative day 1. RESULTS: A significant decrease of pulmonary function was observed in both groups until postoperative day 5. When compared with the percentage of the preoperative value, the forced vital capacity was significantly lower in the OP group than in the IP group on postoperative days 1 (33.3% +/- 8.3% versus 49.1% +/- 8.4%, p < 0.001), 3 (45.4% +/- 7.0% versus 62.1% +/- 8.6%, p < 0.001), and 5 (56.1% +/- 8.7% versus 77.5% +/- 11.6%, p < 0.001). Similar results were found for forced expiratory volume in 1 second on postoperative days 1 (35.7% +/- 8.6% versus 50.0% +/- 9.8%, p < 0.001), 3 (48.4% +/- 7.0% versus 61.5% +/- 9.02%, p < 0.001) and 5 (58.8% +/- 8.5% versus 75.9% +/- 10.2%, p < 0.001). The PaO2 value and the PaO2/FiO2 ratio dropped on postoperative day 1 in both groups (p < 0.05), with a higher fall in the OP group (p < 0.05). Orotracheal intubation time (p = 0.012) and hospital stay (p = 0.002) were lower in the IP group. CONCLUSIONS: Off-pump CABG using the LITA, independently of pleural opening, induced a significant reduction in early postoperative pulmonary function. However, the patients undergoing pleurotomy demonstrated more pronounced pulmonary dysfunction.

Miniesternotomia na cirurgia de revascularização miocárdica preserva função pulmonar pós-operatória / Ministernotomy in myocardial revascularization preserves postoperative pulmonary function

FUNDAMENTO: Na cirurgia de revascularização miocárdica (RM), a necessidade da esternotomia mediana tem sido considerada um fator para a redução de função pulmonar pós-operatória. OBJETIVO: Avaliar prospectivamente a função pulmonar no pós-operatório (PO) precoce de pacientes submetidos à RM sem circulação extracorpórea (CEC), comparando a esternotomia mediana convencional com a miniesternotomia. MÉTODOS: Foram estudados 18 pacientes e alocados em dois grupos: Grupo esternotomia mediana convencional (EMC, n=10) e Grupo miniesternotomia (ME, n=8). Registros espirométricos da capacidade vital forçada (CVF) e do volume expiratório forçado no primeiro segundo (VEF1) foram obtidos antes e no 1º, 3º e 5º dias de PO, e a gasometria arterial, antes e no 1º dia de PO. Também foram avaliados o percentual do shunt pulmonar e o escore de dor. RESULTADOS: Quando comparados em percentual do valor do pré-operatório, a CVF foi maior no grupo ME do que no grupo EMC no 1º, 3º e 5º dias de PO (p<0,001). Resultados similares foram encontrados para o VEF1. A recuperação da CVF entre o 1º e o 5º dia de PO foi maior no grupo EM do que no grupo EMC (p=0,043). A PaO2 diminuiu no 1º dia de PO em ambos os grupos (p<0,05), com maior queda no grupo EMC (p=0,002). O shunt aumentou nos dois grupos no 1º dia de PO (p<0,05), porém foi menor no grupo ME (p=0,02). A dor referida e a permanência hospitalar foram menores no grupo ME. CONCLUSÃO: Pacientes submetidos à cirurgia de RM por miniesternotomia apresentaram melhor preservação e recuperação da função pulmonar que os submetidos à esternotomia mediana.

BACKGROUND: In coronary artery bypass graft (CABG) surgery, the need to perform a midsternotomy has been considered a factor for the decrease in postoperative pulmonary function. OBJECTIVE: To prospectively evaluate early postoperative (PO) pulmonary function in patients submitted to off-pump CABG, comparing the conventional midsternotomy with the ministernotomy approach. METHODS: A total of 18 patients were evaluated and assigned to the two groups: Group Conventional Midsternotomy (CMS, n=10) and Group Ministernotomy (MS, n=8). Spirometric results of the forced vital capacity (FVC) and the Forced Expiratory Volume in one second (FEV1) were obtained on the 1st, 3rd and 5th PO days and the arterial gasometry was obtained before and on the 1st PO day. The pulmonary shunt percentage and the pain score were also assessed. RESULTS: When compared in terms of percentage of the preoperative value, the FVC was higher in the MS group than in the CMS group on the 1st, 3rd and 5th PO days (p<0.001). Similar results were obtained for FEV1. The recovery of the FVC between the 1st and the 5th PO days was higher in the MS than in the CMS group (p=0,043). The PaO2 decreased on the 1st PO day in both groups (p<0.05), with a higher decrease in the CMS group (p=0.002). The shunt increased in the two groups on the 1st PO day (p<0.05); however, it was lower in the MS group (p=0.02). The reported pain score was lower and the duration of the hospital stay was shorter in the MS group. CONCLUSION: Patients submitted to CABG by MS present better preservation and recovery of pulmonary function than those submitted to CMS.

Avaliacão da funcão pulmonar em pacientes submetidos à cirurgia de revascularizacão do miocárdio com e sem circulacão extracorpórea / Evaluation of pulmonary function in patients following on and off-pump coronary artery bypass grafting

OBJETIVO: Avaliar e comparar a funcão pulmonar em pacientes submetidos à cirurgia de revascularizacão do miocárdio (RM) com e sem circulacão extracorpórea (CEC). MÉTODO: Trinta pacientes (média de idade 56,76n10,20 anos) foram alocados em dois grupos, de acordo com a utilizacão ou não da CEC: grupo A (n=15) sem CEC e grupo B (n =15) com CEC. Todos os pacientes foram submetidos à avaliacão da funcão pulmonar. Registros espirométricos da capacidade vital forcada (CVF) e do volume expiratório forcado no primeiro segundo (VEF1) foram obtidos no pré, primeiro, terceiro e quinto dias de pós-operatório (PO) e a gasometria arterial em ar ambiente, no pré e primeiro dia de PO. RESULTADOS: Em ambos os grupos, houve queda significativa da CVF e do VEF1 até o quinto dia de PO (p<0,05). Quando comparados, a diferenca entre os grupos se manteve significativa, com maior queda dos valores de CVF e VEF1 no grupo B (p<0,05). A PaO2 e a relacão PaO2/FiO2 apresentaram queda significativa no primeiro dia de PO em ambos os grupos, porém com maior decréscimo no grupo B (p<0,05). CONCLUSAO: Pacientes submetidos à cirurgia de RM, independentemente do uso da CEC, apresentaram comprometimento da funcão pulmonar no PO. Entretanto, os pacientes operados sem uso da CEC demonstraram melhor preservacão da funcão pulmonar, quando comparados àqueles operados com CEC.

Efeitos do local de inserção do dreno pleural na função pulmonar no pós-operatório de cirurgia de revascularização do miocárdio / Effects of the pleural drain site on the pulmonary function after coronary artery bypass graf

OBJETIVO: Analisar a alteração da função pulmonar e dor em pacientes submetidos à cirurgia de revascularização do miocárdio (RM) com enxerto da artéria torácica interna esquerda (ATIE), sem circulação extracorpórea (CEC), comparando a inserção do dreno pleural nas regiões intercostal e subxifóide. MÉTODO: Vinte e oito pacientes (média de idade 57,4 ± 8,4 anos) foram alocados em dois grupos, de acordo com a posição do dreno pleural. Grupo IL (n=15) com inserção do dreno no sexto espaço intercostal esquerdo na linha axilar média; e grupo IM (n =13) inserção do dreno na região subxifóide. Todos os pacientes foram submetidos à avaliação da função pulmonar. Registros espirométricos da capacidade vital forçada (CVF) e do volume expiratório forçado no primeiro segundo (VEF1) foram obtidos no pré, primeiro, terceiro e quinto dia dias pós-operatório (PO) e a gasometria arterial em ar ambiente no pré e primeiro dia de pós-operatório. A sensação de dor foi quantificada por um escore padrão (0 a 10) no primeiro dia de pós-operatório. RESULTADOS: Em ambos os grupos houve queda significativa da CVF e do VEF1 até o quinto pós-operatório (p<0,001). Quando comparados, a diferença entre os grupos se manteve significativa, com maior queda dos valores de CVF e VEF1 no grupo IL (p<0,05). A pressão parcial de oxigênio arterial apresentou queda significativa no primeiro dia de pós-operatório em ambos os grupos, porém com maior decréscimo no grupo IL (p=0,021). A dor referida foi maior no grupo IL (p=0,002). CONCLUSAO: A cirurgia de RM sem CEC, utilizando a ATIE com pleurotomia esquerda, independente da posição do dreno pleural causa dor e queda significativa na função pulmonar no PO. Porém, a inserção do dreno pleural na região subxifóide demonstrou menor dor subjetiva com melhor preservação da função pulmonar quando comparada à inserção intercostal.

Estudo comparativo entre cefoperazona e gentamicina no tratamento de pacientes com infecçäo bacteriana do trato respiratório baixo / Comparative study between cefoperazone and gentamicin in the treatment of patients with bacterial infections of the lower respiratory tract

Foram estudados 20 pacientes portadores de infecçöes do trato respiratório inferior, divididos em dois grupos de 10 pacientes, sendo um tratado com cefoperazona, isolada, 2 g I.V. de 12/12 h (grupo I) e outro com gentamicina 60 mg I.M. de 8/8 h (grupo II), isolada ou associada à ampicilina 1 g I.V. de 6/6 horas. Do ponto de vista clínico, nove pacientes do grupo I e 10 do grupo II apresentaram cura ou melhora clínica. Com relaçäo à eficácia bacteriológica, oito pacientes do grupo I e 6 do grupo II evidenciaram erradicaçäo ou erradicaçäo com contaminaçäo. Houve persistência do germe inicial em dois pacientes do grupo I e em 4 do grupo II. A avaliaçäo global foi excelente e boa em oito pacientes do grupo I e em 9 do grupo II. A análise estatística (teste de Fischer) näo mostrou diferença significativa entre os tratamentos, em nenhum dos parâmetros supracitados. Näo foram observadas reaçöes adversas durante a terapêutica em ambos os grupos. A cefoperazona mostrou ter eficácia e segurança similar ao uso da gentamicina, isolada ou associada à ampicilina, no tratamento das infecçöes do trato respiratório inferior