Effect of postoperative high load long duration inspiratory muscle training on pulmonary function and functional capacity after mitral valve replacement surgery: A randomized controlled trial with follow-up.

OBJECTIVES: Although, pre-operative inspiratory muscle training has been investigated and reported to be an effective strategy to reduce postoperative pulmonary complications, the efficacy of postoperative inspiratory muscle training as well as the proper load, frequency, and duration necessary to reduce the postoperative pulmonary complications has not been fully investigated. This study was designed to investigate the effect of postoperative high-load long-duration inspiratory muscle training on pulmonary function, inspiratory muscle strength, and functional capacity after mitral valve replacement surgeries. DESIGN: Prospective randomized controlled trial. METHODS: A total of one hundred patients (mean age 38.3±3.29years) underwent mitral valve replacement surgery were randomized into experimental (n = 50) and control (n = 50) groups. The control group received conventional physiotherapy care, while experimental group received conventional care in addition to inspiratory muscle training, with 40% of the baseline maximal inspiratory pressure targeting a load of 80% by the end of the 8 weeks intervention protocol. Inspiratory muscle training started on the patient's first day in the inpatient ward. Lung functions, inspiratory muscle strength, and functional capacity were evaluated using a computer-based spirometry system, maximal inspiratory pressure measurement and 6MWT respectively at 5 time points and a follow-up assessment was performed 6 months after surgery. Repeated measure ANOVA and post-hoc analyses were used (p <0.05). RESULTS: Group-time interactions were detected for all the studied variables (p<0.001). Between-group analysis revealed statistically significant postoperative improvements in all studied variables in the experimental group compared to the control group (p <0.001) with large effect size of η2 ˃0.14. Within-group analysis indicated substantial improvements in lung function, inspiratory pressure and functional capacity in the experimental group (p <0.05) over time, and these improvements were maintained at follow-up. CONCLUSION: High intensity, long-duration postoperative inspiratory muscle training is highly effective in improving lung function, inspiratory muscle strength, and functional capacity after mitral valve replacement surgeries.

Capacidade pulmonar e funcional no pós-operatório de mulheres submetidas à mastectomia: série de casos / Pulmonary and functional capacity in the post-surgery of women submitted to mastectomy: preliminary results

Mulheres submetidas à cirurgia de mastectomia podem apresentar algumas complicações, dentre elas, alterações respiratórias e prejuízo funcional. O objetivo deste estudo foi avaliar a cinemática da parede torácica e a capacidade funcional no pós-operatório de pacientes mastectomizadas sem tratamento neoadjuvante e adjuvante associados. Foram avaliadas 4 mulheres no grupo mastectomia (GM) e 4 mulheres no grupo controle (GC). Todas as participantes foram submetidas aos procedimentos de avaliação antropométrica, função pulmonar, força muscular respiratória, cinemática da parede torácica e capacidade funcional. O GM também foi submetido à avaliação de inspeção e palpação torácica. Os dados foram analisados por meio de estatística descritiva. Foi observado que o GM apresentou menor variação de volume corrente da parede torácica, com delta de variação de 22,03% a menos que o GC, sendo a maior redução de volume corrente evidenciada no compartimento de caixa torácica pulmonar, com redução de 41,57% em relação ao GC. O GM não apresentou alterações de função pulmonar, força muscular respiratória e capacidade funcional, apresentando valores de normalidade nessas avaliações. Portanto, mulheres submetidas ao procedimento cirúrgico de mastectomia, sem tratamento neoadjuvante e adjuvante associados, não apresentaram comprometimento da função pulmonar, da força muscular respiratória e da capacidade funcional, contudo foi verificado redução do volume pulmonar na região do procedimento cirúrgico.

Women submitted to a mastectomy surgery may present some complications, among them, respiratory changes and functional impairment. The purpose of this study was to evaluate the chest wall kinematics and functional capacity in the postoperative period of mastectomized patients without associated adjuvant and neoadjuvant treatment. A total of four (4) women in the mastectomy group (MG) and four (4) in the control group (CG) were evaluated. All participants were submitted to the procedures of anthropometric evaluation, pulmonary function, respiratory muscle strength, chest wall kinematics and functional capacity. Patients in MG were also submitted to an inspection and palpation evaluation of the chest and breasts. Database was analyzed using descriptive statistics. It was observed that the MG presented a smaller variation of tidal volume of the chest wall, with a variation delta of 22.03% less than CG, with the largest reduction in tidal volume evidenced in the pulmonary chest cavity compartment, with a reduction of 41.57% when compared to CG. The MG did not present alterations of pulmonary function, respiratory muscle strength and functional capacity, presenting values of normality in these evaluations. Therefore, women submitted to the surgical procedure of mastectomy without associated neoadjuvant and adjuvant treatment did not present any impairment of pulmonary function, respiratory muscle strength and functional capacity. However, a reduction could be observed in the pulmonary volume in the region of the surgical procedure.

Operative management of acquired thoracic dystrophy in adults after open pectus excavatum repair.

BACKGROUND: In young children, acquired thoracic dystrophy (ATD) is associated with extensive resection of cartilage, often during open pectus excavatum (PE) repair. Progressive dyspnea or exercise intolerance may develop in these patients secondary to cardiac compression or restrictive pulmonary function. Surgical treatment of ATD by attempting to increase the overall thoracic volume has been controversial. We describe our experience with adults presenting for surgical correction of ATD. METHODS: A retrospective medical record review was performed for all patients with ATD presenting for surgical evaluation from December 2010 through February 2013. RESULTS: Ten adult male patients were evaluated for treatment of ATD after an open Ravitch procedure for PE. Nine patients, whose mean age was 34 years (range, 21-42 years), elected to proceed with surgical treatment. The mean age of the initial repair was 3.7 years. Extensive reconstruction, chest wall expansion, and placement of stainless steel support bars and titanium plating were performed in all patients. Eight patients had minor complications, and major complications occurred in 3 patients. Respiratory failure with prolonged ventilator support occurred in 3 patients. There were no reoperations or deaths. At mean follow-up of 16 months (range, 6-31 months), all patients subjectively reported improvement in their ability to exercise and in their symptoms, including dyspnea with exertion. CONCLUSIONS: ATD may be associated with early childhood Ravitch repair. Adults may present with disabling symptoms related to cardiac compression and restrictive pulmonary function. Reconstruction with sternal elevation and expansion of the anterior chest subjectively improves symptoms.

Respiratory management in the patient with spinal cord injury.

Spinal cord injuries (SCIs) often lead to impairment of the respiratory system and, consequently, restrictive respiratory changes. Paresis or paralysis of the respiratory muscles can lead to respiratory insufficiency, which is dependent on the level and completeness of the injury. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Vital capacity (VC) is an indicator of overall pulmonary function; patients with severely impaired VC may require assisted ventilation. It is best to proceed with intubation under controlled circumstances rather than waiting until the condition becomes an emergency. Mechanical ventilation can adversely affect the structure and function of the diaphragm. Early tracheostomy following short orotracheal intubation is probably beneficial in selected patients. Weaning should start as soon as possible, and the best modality is progressive ventilator-free breathing (PVFB). Appropriate candidates can sometimes be freed from mechanical ventilation by electrical stimulation. Respiratory muscle training regimens may improve patients' inspiratory function following a SCI.

Isokinetic muscle strength after thoracotomy: standard vs. muscle-sparing posterolateral thoracotomy.

BACKGROUND: The aim of the study was to compare the effects of conventional posterolateral thoracotomy and muscle-sparing posterolateral thoracotomy on pulmonary and muscle strength. METHODS: From January 2003 to December 2004, 50 randomized patients with a diagnosis of primary lung cancer underwent pulmonary resection. The patients were divided into two groups: Group I (n=25) underwent conventional posterolateral thoracotomy, while Group II (n=25) had muscle-sparing thoracotomy. The groups were compared in terms of shoulder abduction/adduction isokinetic muscle strength and respiratory muscle strength. RESULTS: A comparison of maximal expiratory pressure and maximal inspiratory pressure preoperatively and postoperatively and of maximal expiratory pressure and maximal inspiratory pressure preoperatively and at 3 months postoperatively showed statistically significant differences (P<0.05). CONCLUSION: For the preservation of muscle strength, especially in patients whose jobs involved manual work, muscle-sparing posterolateral thoracotomy should be the first choice rather than conventional thoracotomy. Moreover, if necessary, the latissimus dorsi muscle can be used more extensively as a flap after muscle-sparing posterolateral thoracotomy procedures.

Noninvasive respiratory muscle aids during PEG placement in ALS patients with severe ventilatory impairment.

UNLABELLED: Although no clear recommendations are given about when percutaneous endoscopic gastrostomy (PEG) should be placed in amyotrophic lateral sclerosis (ALS) patients, some experts underline the risk of respiratory complications when patients had severe ventilatory muscle impairment (SVMI). AIM: To evaluate the efficacy of noninvasive ventilation (NIV) and mechanically assisted cough (MAC) to avoid respiratory complications related to PEG placement in ALS patients with SVMI. MATERIAL AND METHODS: Prospective study including ALS patients who had chosen to have PEG placement timed by swallowing dysfunction with the aid of NIV and MAC if needed. PEG was carried out under volume-cycled NIV through a nasal mask. MAC was applied prior to and at the end of the procedure. RESULTS: Thirty ALS patients (60.43±12.03years) were included. Prior to PEG placement: BMI 25.0±4.6kg/m(2), ALSRFS-R 19.5±5.0, Norris bulbar sub-score 15.1±6.6, %FVC 35.9±18.1%, PCF 2.3±1.2L/s, PImax -35.6±24.6cmH(2)O, and PEmax 40.5±23.9cmH(2)O. Three patients had PEG placement under tracheotomy ventilation because NIV SpO(2) was below 88%. No patient died during the procedure nor did any have respiratory complications. Survival at 1month was 100%. CONCLUSION: Respiratory support provided by volume-cycled NIV and MAC permits successful PEG placement in most ALS patients with SVMI.

Muscle sparing thoracotomy in pediatric age: a comparative study with standard posterolateral thoracotomy.

Alternative approaches to the standard posterolateral incision for thoracotomy have been developed to minimize its postoperative pain and wound related side effects. Muscle-sparing (MS) thoracotomy has been a well-known substitution to the standard posterolateral thoracotomy for this purpose; however it has not been studied in the pediatric age group in detail. We studied retrospectively the patients with thoracotomy for non-cardiac, thoracic surgical procedures. Group 1 included the patients with standard posterolateral thoracotomy for the surgery. The patients with MS thoracotomy composed group 2. The related data were collected retrospectively. The early postoperative morbidities (time requiring for regaining shoulder girdle movement, extubation, intensive care unit stay, and hospital stay) and late musculoskeletal anomalies (scoliosis, elevation of the shoulder, winged scapula, asymmetry of the nipples) were compared between groups. A total of 90 patients were included in the study. Group 1 constituted 50 patients with an average age of 4.24 +/- 2.91 years. Group 2 included 40 patients with an average age of 4.20 +/- 2.92 years. Comparison of the demographics and the baseline characteristics of the patients were not different between groups. In comparison of operative characteristics, there was lesser morbidity in group 2 as re-exploration for bleeding, wound infection, wound healing and fewer intensive care unit and hospital stay days. Late follow-up revealed a significant increase in musculoskeletal deformities in group 1. We conclude that muscle-sparing incision should be preferred to the standard posterolateral thoracotomy in pediatric age.

Estudo das repercussöes das cirurgias abdominais sobre os músculos respiratórios / Study of repercussion of abdominal surgeries under the respiratory muscle

O presente estudo tem como principal objetivo avaliar a funçäo da musculatura respiratória em pacientes submetidos a cirurgias abdominais, comparando o grau de comprometimento ventilatório entre a laparotomia e laparoscopia. As avaliaçöes foram feitas em 9 pacientes no pré e pós-operatório, que realizaram os seguintes testes: PIM, PEM, PEAK FLOW, cirtometria, força muscular respiratória; e ainda, um RX de tórax para visualizar a excursäo do diafragma. Foram observadas alteraçöes nos valores mensurados entre os período testados, especialmente nos pacientes que realizaram cirurgia de maior porte e laparotomia

Reconstrucción mamaria post-mastectomía: diferentes alternativas / Immediate breast reconstruction: different alternatives

Material y métodos: Se presentan 313 mujeres a quienes se les realizó reconstrucción mamaria entre enero de 1981 y diciembre de 1998. En 263 pacientes se realizó colgajo miocutáneo de dorsal ancho, en 42 colgajo miocutáneo de recto anterior del abdomen y en 32 expansor tisular. De éstas, 85 por ciento se realizaron en forma simultánea a la mastectomía y 15 por ciento diferida. Resultados: El 25 por ciento de los expansores colocados debieron ser retirados por complicaciones. Conclusiones: La edad de la enferma no contraindica la reconstrucción. No existe un método mejor que otro, sino que según las distintas circunstancias, cada técnica tiene sus indicaciones. Si no existen contraindicaciones precisas, la reconstrucción inmediata presenta excelentes resultados estéticos, sin comprometer la evolución oncológica y colocando a la mujer en una mejor posición psicológica para enfrentar su enfermedad

Reconstrucción mamaria post-mastectomía: diferentes alternativas / Immediate breast reconstruction: different alternatives

Material y métodos: Se presentan 313 mujeres a quienes se les realizó reconstrucción mamaria entre enero de 1981 y diciembre de 1998. En 263 pacientes se realizó colgajo miocutáneo de dorsal ancho, en 42 colgajo miocutáneo de recto anterior del abdomen y en 32 expansor tisular. De éstas, 85 por ciento se realizaron en forma simultánea a la mastectomía y 15 por ciento diferida. Resultados: El 25 por ciento de los expansores colocados debieron ser retirados por complicaciones. Conclusiones: La edad de la enferma no contraindica la reconstrucción. No existe un método mejor que otro, sino que según las distintas circunstancias, cada técnica tiene sus indicaciones. Si no existen contraindicaciones precisas, la reconstrucción inmediata presenta excelentes resultados estéticos, sin comprometer la evolución oncológica y colocando a la mujer en una mejor posición psicológica para enfrentar su enfermedad (AU)

Comparison of conventional surgical versus Seldinger technique emergency cricothyrotomy performed by inexperienced clinicians.

BACKGROUND: Cricothyrotomy is the ultimate option for a patient with a life-threatening airway problem. METHODS: The authors compared the first-time performance of surgical (group 1) versus Seldinger technique (group 2) cricothyrotomy in cadavers. Intensive care unit physicians (n = 20) performed each procedure on two adult human cadavers. Methods were compared with regard to ease of use and anatomy of the neck of the cadaver. Times to location of the cricothyroid membrane, to tracheal puncture, and to the first ventilation were recorded. Each participant was allowed only one attempt per procedure. A pathologist dissected the neck of each patient and assessed correctness of position of the tube and any injury inflicted. Subjective assessment of technique and cadaver on a visual analog scale from 1 (easiest) to 5 (worst) was conducted by the performer. RESULTS: Age, height, and weight of the cadavers were not different. Subjective assessment of both methods (2.2 in group 1 vs. 2.4 in group 2) and anatomy of the cadavers (2.2 in group 1 vs. 2.4 in group 2) showed no statistically significant difference between both groups. Tracheal placement of the tube was achieved in 70% (n = 14) in group 1 versus 60% (n = 12) in group 2 (P value not significant). Five attempts in group 2 had to be aborted because of kinking of the guide wire. Time intervals (mean +/- SD) were from start to location of the cricothyroid membrane 7 +/- 9 s (group 1) versus 8 +/- 7s (group 2), to tracheal puncture 46 +/- 37s (group 1) versus 30 +/- 28s (group 2), and to first ventilation 102 +/- 42s (group 1) versus 100 +/- 46s (group 2) (P value not significant). CONCLUSIONS: The two methods showed equally poor performance.

Treatment of infected median sternotomy wounds with a myocutaneous latissimus dorsi muscle flap.

Infected sternotomy wounds, particularly if accompanied by osteomyelitis, mediastinitis or pericarditis, are associated with significant morbidity, prolonged hospitalization and a mortality of up to 50%. Until the introduction of muscle flaps, the therapy of choice was debridement and open granulation or catheter irrigation. From 1994 to 1996, 9 patients with infected median sternotomy wounds were treated with a single-stage radical debridement and wound closure with a pedicled myocutaneous latissimus dorsi muscle flap (LDM). One patient received, in addition, a rectus abdominis muscle turnover flap. Healing was uneventful in all cases, with no respiratory complications or chest-wall instability. Shoulder strength was also unaffected. Functional and aesthetic outcome was good. The LDM provides a safe flap with little donor site morbidity. Compared to the most local muscle flaps, an intact IMA is not required. At the same time, length and cost of hospital stay are decreased.

Acute and chronic morbidity differences between muscle-sparing and standard lateral thoracotomies.

INTRODUCTION: Opinions differ regarding differences between totally muscle-sparing thoracotomy and standard lateral thoracotomy approaches to pulmonary resection with respect to operative time, postoperative pain and morbidity, and occurrence of chronic postthoracotomy pain syndromes and subjective shoulder dysfunction. METHODS: Three hundred thirty-five consecutive patients undergoing muscle-sparing thoracotomy (n = 148) or lateral thoracotomy (n = 187) to accomplish lobectomy for stage I lung cancer during a 40-month period were evaluated. Local rib resection was not employed, and two chest tubes were routinely used after operation in both thoracotomy groups. Epidural analgesia use was similar after operation in the two groups (muscle-sparing thoracotomy 38%, lateral thoracotomy 38%). The postoperative hospital courses and patient functional statuses at 1 year were examined. RESULTS: Demographic analyses demonstrated no differences between groups in age, sex, or association of significant comorbid medical illness. Although the operative time required for muscle-sparing thoracotomy was shorter, there were no differences between thoracotomy approaches in any of the other primary acute postoperative variables analyzed (chest tube duration, length of hospital stay, postoperative narcotic requirements, and postoperative mortality). The frequencies of chronic pain and shoulder dysfunction assessed 1 year after operation were also similar between thoracotomy groups. CONCLUSIONS: The relative efficacies and rates of occurrence of acute or chronic morbidity are equivalent after muscle-sparing thoracotomy and standard lateral thoracotomy. Although muscle-sparing thoracotomy may possibly be performed more expediently, it appears that the singular advantage of muscle-sparing thoracotomy over standard lateral thoracotomy involves the preservation of chest wall musculature in case rotational muscle flaps should be needed later.