Purpose of the research: PICO Question In the rehabilitation of post open heart patients, how effective is the use of an incentive spirometer versus not using one to decrease the chance of pulmonary complications? Purpose of the research: To evaluate how effective incentive spirometry is for post open heart patients. Holly Owen COHP 450

How Research was conducted Key Words used: Post Cardiac Surgery Post Open Heart Surgery Incentive Spirometer/ Spirometry Pulmonary Complications Search Engines Used: CINHAL PubMed Google Scholar

Research Found Carvalho, C., Lunardi, A., & Paisani, D. (2011). Incentive spirometer in major surgeries: A systematic review. Brazilian Journal of Physical Therapy, 15(5). 343-350. Retrieved from: http://www.scielo.br/pdf/rbfis/v15n5/AOP027- 11.pdf. Gupta, V. T., Moiz, J. A., & Mueenubheen, T. P. (2012). A comparative study on the effects of incentive spirometry and deep breathing exercise on pulmonary functions after uncomplicated coronary artery bypass grafting surgery. Indian Journal of Physiotherapy and Occupational Therapy, 6(2). 63- 67. Retrieved from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.464.8883&rep=r ep1&type=pdf#page=67.

How the Research Found Relates to Original PICO Question The study conducted by Carvalho, Lunardi, and Paisani, (2011), evaluated the effectiveness of incentive spirometry (IS) use in post abdominal, cardiac and thoracic surgery patients: Systematic Review of 30 studies 14 abdominal, 13 cardiac and 3 thoracic. 5 studies compared the effect of IS with a control group (no intervention). 3 abdominal, 1 cardiac and 1 thoracic Research conducted by Gupta, Moiz, and Mueenudheen, (2012), compared the effectiveness of incentive spirometer use versus deep breathing exercises after uncomplicated coronary artery bypass grafting (CABG).

Research of Carvalho, Lunardi & Paisani, (2011) Theory: No recent evidence to back up use of IS. New study needed to be conducted. (Cavalho, Lunardi and Paisani, 2011). Methods: Searches performed with Medline, Embase, Web of Science, PEDro and Scopus. Randomized Controlled Trials only. Cut down from 250 original studies to only 30 that met the inclusion criteria. Specific outcome evaluated Key words used for the search Two reviewers independently assessed the studies. (Cavalho, Lunardi and Paisani, 2011). Design: Quantitative Systematic Review of Randomized Controlled Trials.

Research of Carvalho, Lunardi & Pasani, (2011) Continued Results: Will focus only on the cardiac portion Only one post-operative cardiac study with a control (no intervention) group No difference was found between the groups for decreasing pulmonary complications. Nine studies focused on the evaluation of pulmonary complication incidences post-op, but compared it to another intervention Two studies used exercise with positive pressure in conjunction to IS One of the studies found a reduction of pulmonary complications The other study found IS to be less effective than positive pressure The other seven studies evaluated found no evidence that IS decreases pulmonary complications. The overall consensus from the entire trial was that there is insufficient evidence to back IS use. (Cavalho, Lunardi and Paisani, 2011).

Research of Gupta, Moiz & Mueenubheen, (2012) A quantitative, experimental design. Methods: 16 subjects in Group A used IS 16 subjects in Group B used a deep breathing technique Both groups were observed daily to perform 3 sets of 10 consecutive breaths with a pause of a minute between each set. PFTs Pre-op, Post-op, POD 3 ABGs directly before and after daily set. (Gupta, Moiz, Mueenudheen, 2012). Theory: Is there a clinical difference in the effectiveness of IS use or deep breathing exercises in post-op CABG? (Gupta, Moiz, Mueenudheen, 2012). Characteristic Mean (+,-) Group A (IS) Group B (DB) Age (yrs) 53.87 (+, -) 9.85 53.87 (+,-) 8.08 Height (cm) 164.5 (+,-) 7.80 163.5 (+,-) 6.81 Weight (kg) 61.81 (+,-) 10.0 65.13 (+,-) 10.81 BMI (kgm-2) 22.87 (+,-) 3.28 24.75 (+, -) 4.61

Research of Gupta, Moiz & Mueenubheen, (2012) Results Results: Although each group had improvement in PFTs and ABGs with both exercises, there was no significant clinical difference between the two. (Gupta, Moiz, Mueenudheen, 2012). (Gupta, Moiz, Mueenudheen, 2012).

Ethics in the Research Carvalho, Lunardi & Paisani, (2011): Conselho Nacional de Desenvolvimento Científico e Tecnológico provided funding for the research. Literature review, so no subject consent was necessary. Brazilian Journal of Physical Therapy is a peer reviewed journal. Gupta, Moiz & Mueenubneen, (2012): Informed consent was obtained from the patients prior to research. “Indian Journal of Physiotherapy and Occupational Therapy is a multidisciplinary refereed journal devoted to disseminating rigorous research on all aspects of the physiotherapy occupational therapy to enhance learning,” (Indian Journal of Physiotherapy and Occupational Therapy, 2012). No ethical concerns were found. Unable to find how the research was funded.

Strength, Quality and Credibility Both studies were credible in that they are from peer reviewed journals. Downfalls: Carvalho, Lunardi & Paisiani, (2011): Patient follow-up period short Most of the IS studies were in conjunction with another intervention. Many of the studies had a small sample size. Issues of experimental design Lack of randomization Bias? Only one cardiac study with control group Only studies published in English, Portuguese and Spanish used. Gupta, Moiz & Mueenubheen, (2012): Limited time frame of 2 days pre-op and 3 days post-op.

Strength, Quality and Credibility Continued (Quality Control/ Strengths): Carvalho, Lunardi, Paisiani, (2011): Randomized controlled trials evaluating IS use pre and post-op in abdominal, thoracic and cardiac procedures. Studies involving the following outcomes were included: “pneumonia, atelectasis, pulmonary function, oxygenation and hospital stay length followed-up for at least two days of postoperative care,” (Carvalho, Lunardi, Pasani, 2011). The reviewers assessed the quality of the studies according to the PEDro (Physiotherapy Evidence Database) scale. The scale ranges from 0 to 10 according to the following data: “eligibility and source of patients, random allocation of the participants, concealed allocation, baseline comparability between the groups with regards to the most important prognostic indicators, blinding of participants, blinding of the therapists who administered the therapy, blinding of the assessor who measured the outcomes, measurements of outcomes were obtained from more than 85% of the participants included in the study, intention-to- treat analysis, description of the between-group statistical comparisons, provides both point measures and measures of variability for the outcomes,” (Carvalho, Lunardi, Pasani, 2011). All eligible studies required a PEDro score of greater than or equal to 5.

Strength, Quality and Credibility Continued (Quality control/ Strengths): Gupta, Moiz & Mueenubheen, (2012). Only uncomplicated post-op CABG patients were utilized for the study. Patients experiencing complete heart block on external pacemaker, hypotension (<90/60 mmHg), hypertension (>180/100 mmHg), cardiac arrhythmias, and those requiring mechanical ventilation >24 hours were excluded from the study. Patients ranging in ages 38 to 68 years old. Only those undergoing an elective CABG. Subjects were studied in a randomized manner. Technique was observed.

Evidence Based Practice (EBP) Research of Carvalho, Lunardi & Paisani, (2011). Not strong enough to cause change for EBP. Too much lacking data Too many variables in the study. Research of Gupto, Moiz & Mueenubheen, (2012). Strong case to show that both deep breathing and IS impact equally on lung function. Did not evaluate the incidence of pulmonary complications. Not a strong enough case to cause a change in EBP. Most recent EBP shows that IS use is recommended for most postoperative patients, (US Department of Health and Human Services, 2011).

Relevance to Practice Further research is necessary before any changes to practice can be made. No real implications toward changing practice at this time. Little research was available on the subject matter Ultimately, incentive spirometry is a good indicator of lung capacity, but little research shows to efficacy to prevent pulmonary complications. More subjects with a control group. Such as: Ambulation, and cough and deep breathe only, and ambulation, and coughing and deep breathing with IS use. Gupta, Moiz and Mueenubheen, (2012), was generalizable. Able to transpose onto any other post CABG unit. Found that no change was present. Therefore, no implication on changing practice.

Additional PICO questions: In post-operative cardiac surgery patients, is deep breathing exercises or incentive spirometer use more effective in preventing pulmonary complications and improving lung function? In post-operative surgery patients, do patients that are compliant with incentive spirometer have less pulmonary complications versus those that are noncompliant?

Conclusion The two studies found little evidence to back up incentive spirometer use. Difficult to find research on the subject. Need further post-operative research.

References Carvalho, C., Lunardi, A., & Paisani, D. (2011). Incentive spirometer in major surgeries: A systematic review. Brazilian Journal of Physical Therapy, 15(5). 343-350. Retrieved from: http://www.scielo.br/pdf/rbfis/v15n5/AOP027- 11.pdf. Gupta, V. T., Moiz, J. A., & Mueenubheen, T. P. (2012). A comparative study on the effects of incentive spirometry and deep breathing exercise on pulmonary functions after uncomplicated coronary artery bypass grafting surgery. Indian Journal of Physiotherapy and Occupational Therapy, 6(2). 63- 67. Retrieved from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.464.8883&rep=r ep1&type=pdf#page=67. U.S. Department of Health and Human Services, (2011). Guideline title: Incentive spirometry, 2011. Retrieved from: http://www.guideline.gov/content.aspx?id=34793#Section424