Effects of Incentive Spirometry
Exercises on Pulmonary Function and Dyspnea in Patients Undergoing Acute
Coronary Artery Bypass Grafting
Dr.
S. Dilly Prasad 1*, Dr. N. Siva Harish2
1 Assistant
Professor MPT, KKC College of Physiotherapy,
Puttur, Tirupathi, Andhra Pradesh, India
sivanarasapuram@gmail.com
2 Associate Professor
MPT, KKC College of Physiotherapy,
Puttur, Tirupathi, Andhra Pradesh, India
Abstract
Background: CABG (Coronary Artery Bypass Grafting) is a
procedure that is frequently performed to treat severe cases of coronary artery
disease. Postoperative
pulmonary complications such as reduced pulmonary function and dyspnea
frequently occur following CABG due to anesthesia, sternotomy, and reduced
mobility. Respiratory physiotherapy interventions, including incentive
spirometry, are commonly used to improve lung expansion and prevent pulmonary
complications during the postoperative period.
Objective: To study the effect of
incentive spirometry exercises on pulmonary function and dyspnea in patients
undergoing Coronary Artery Bypass Grafting.
Methods: A
randomized study was carried out with 30 patients who underwent CABG surgery,
aged between 50 and 60 years. Participants were randomly allocated into two
groups, each consisting of 15 participants. The experimental group (GROUP A) received conventional
physiotherapy exercises along with incentive spirometry exercises, while the
control group (GROUP B) received conventional physiotherapy exercises alone.
The intervention was administered five sessions per week for three weeks.
Pulmonary function was assessed using spirometry by measuring Forced Expiratory
Volume in one second (FEV₁), and dyspnea was assessed using the Borg
Dyspnea Scale before and after the intervention.
Results:
Experimental group shows statistically significant improvement in patients with
acute coronary artery bypass grafting when compared with control group.
Conclusion: Incentive spirometry exercises
combined with conventional physiotherapy significantly improve pulmonary
function and reduce dyspnea in patients undergoing CABG during the
postoperative period.
Keywords: Coronary artery bypass
grafting, incentive spirometry, pulmonary function, dyspnea, physiotherapy
rehabilitation.
INTRODUCTION
Coronary artery disease (CAD) remains a primary contributor to global morbidity and mortality. The World Health Organization has indicated that cardiovascular diseases accounted for 31% of all deaths in 2019.Coronary heart disease (CHD) arises from the accumulation of atherosclerotic plaque within the coronary arteries, which leads to progressive narrowing and diminished myocardial blood supply. Severe arterial obstruction may present clinically as angina, dyspnea, or myocardial infarction.
Coronary
Artery Bypass Grafting (CABG) is a well-established surgical intervention
performed to restore adequate myocardial perfusion in patients with significant
coronary artery blockage. The procedure involves grafting a healthy artery or
vein—most commonly the internal thoracic artery or the great saphenous vein—to
bypass the obstructed coronary segment. This creates an alternative pathway for
oxygen-rich blood to reach the myocardium. CABG may be performed using
conventional cardiopulmonary bypass with cardiac arrest or through off-pump
techniques on a beating heart. The procedure is associated with improved
symptom relief, enhanced functional capacity, and better long-term survival in
appropriately selected patients [1, 2,3]
However,
postoperative pulmonary complications remain common after CABG. Factors such as
general anesthesia, sternotomy, postoperative pain, and prolonged
immobilization contribute to reduced lung volumes, impaired ventilation,
respiratory muscle weakness, and atelectasis. These alterations frequently
result in decreased pulmonary function and increased perception of dyspnea
during the early recovery phase, potentially delaying rehabilitation and
prolonging hospital stay. [4, 5]
Incentive
spirometry is a commonly prescribed respiratory therapy that promotes sustained
maximal inspiration through slow, deep breathing exercises with visual
feedback. Regular practice facilitates lung expansion, improves ventilation,
strengthens the respiratory musculature, and helps prevent atelectasis.
Dyspnea, defined as a subjective experience of breathing discomfort, is
commonly assessed using tools such as the Modified Borg Scale and plays a significant
role in evaluating postoperative recovery. [5, 6]
Although
incentive spirometry is routinely incorporated into postoperative care
following CABG, limited evidence exists regarding its combined effect on
objective pulmonary function parameters and subjective dyspnea levels in acute
CABG patients. This gap in evidence necessitates further investigation. [7,
8]
NEED OF THE STUDY
CABG is a
standard surgical intervention for patients with severe coronary artery disease;
however, postoperative pulmonary complications remain frequent. Reduced lung
volumes, impaired ventilation, and respiratory muscle weakness often lead to
decreased pulmonary function and increased dyspnea during the acute recovery
period. Incentive spirometry is routinely prescribed to prevent these
complications and promote lung expansion. Although widely used, limited
evidence exists regarding the combined effect of this approach on objective
pulmonary function parameters and subjective dyspnea in acute CABG patients.
Therefore, systematic evaluation of incentive spirometry in this population is
necessary to support evidence-based postoperative rehabilitation practices.
AIM
OF THE STUDY
To determine the effects
of incentive spirometry exercises on pulmonary function
and dyspnea in CABG patients.
OBJECTIVES
1. To examine the impact of incentive spirometry exercises on pulmonary function in patients undergoing CABG.
2. To examine the impact of incentive spirometry exercises on dyspnea in patients undergoing CABG.
v Patients
aged 50-60 years.
v Both male and female participants.
v Acute stage Patients (less than 3 months after
surgery).
v Patients
with a dyspnea score greater than 7 on
the Borg Scale.
v Patients
with unstable angina.
v Patients
with severe renal dysfunction.
v Patients
with a history of cardiac surgery
greater than 3 months.
v Patients
are unable to perform the required
exercises or assessments.
OUTCOME MEASURES
1. Pulmonary Function (FEV₁): Pulmonary function was measured using spirometry by recording Forced Expiratory Volume in one second (FEV₁) before and after the intervention.
2. Dyspnea: Dyspnea was assessed using the Borg Dyspnea Grading Scale before and after the intervention.
Thirty patients from SVRRGGH Hospital
who had CABG were chosen at random. Patients between the ages of 50 and 60 of
both sexes were included in the study. The selected patients were split into
two groups at random: a control and an experimental group, each with 15
patients.
The experimental group received conventional
physiotherapy exercises along with incentive spirometry exercises, whereas the
control group received conventional physiotherapy exercises alone. Before
surgery, all subjects were assessed by a physiotherapist and were educated
about the postoperative physiotherapy protocols and interventions. Routine
physiotherapy maneuvers were explained and demonstrated to the participants.
Patients were provided with a detailed explanation of the study methodology before the intervention began, and informed consent was obtained. Baseline assessment of vital signs was performed. Pulse rate was measured by palpating the radial pulse using the first three fingers for 60 seconds. Respiratory rate was assessed immediately after pulse measurement by observing the movement of the abdomen in male patients and the thoracic movement in female patients.
Patients were included in the training only after
confirming medical stability and appropriate medical management. Nutritional
status and medication adherence were ensured before initiating the intervention.
Dyspnea and pulmonary function were assessed both prior to and following the
conclusion of the intervention period.
Patients in the experimental group received conventional physiotherapy exercises combined with incentive spirometry exercises and relaxation techniques. The training program consisted of five sessions per week for three weeks. Each session lasted approximately 20 minutes. Incentive spirometry was performed in two sets of ten deep breaths with a five-minute rest interval between sets.
Patients were told to hold the incentive spirometer
upright, exhale normally, and tighten their lips over the mouthpiece while
performing the exercise. After
that, they were told to take a deep, slow breath to elevate the balls in the
chamber to the desired level. They were then asked to hold their breath for
around five seconds before exhaling normally.. Incentive
spirometry encourages sustained maximal inspiration and provides visual
feedback to facilitate lung expansion and prevent atelectasis. The device
contains three chambers with colored balls representing airflow rates of
approximately 600 ml/sec, 900 ml/sec, and 1200 ml/sec.
Patients in the experimental group were positioned
comfortably with the head end of the bed elevated up to forty-five degrees. The exercises were performed on the
1st postoperative day and on the 2nd and 3rd postoperative
days while sitting upright with back support.
Figure 1 & 2: INCENTIVE SPIROMETRY EXERCISES
Patients in the control group received conventional
physiotherapy exercises, including deep breathing, diaphragmatic breathing,
pursed-lip breathing, paced breathing, and segmental breathing exercises.
Patients were positioned comfortably in upright sitting or Fowler’s position
with back support during the exercises. One hand was placed on the chest and
the other on the abdomen to facilitate diaphragmatic breathing.
Airway clearance techniques such as coughing and the
forced expiratory technique were also taught. In CABG patients, coughing was
performed with splinting by applying pressure over the surgical incision using
a pillow or belt to reduce pain and support the surgical site. DURATION: 20
Minutes for each session, 5 sessions per 3 weeks
Figure 3: Conventional Physiotherapy
Exercises
STATISTICAL
ANALYSIS
Microsoft
Excel 2007 and SPSS were used for the statistical analysis and data
interpretation. Each group's changes prior to and during the intervention were
compared using a pair of t-tests, whereas changes following the intervention
were compared using an unpaired t-test. P <0.0001was
found to be statistically significant.
Table 1: Means Of Spirometry (FEV₁) For Group A
& Group B Descriptive
statics
|
GROUP
A |
Paired t- test |
||
|
Comparison of Spirometry
(FEV₁) |
Mean ± SD |
t-
value |
p-
value |
|
Pre-Test |
67.60
± 6.32 |
11.418 |
<0.0001 |
|
Post-Test |
83.53
± 4.21 |
||
|
GROUP
B |
Paired t- test |
||
|
Comparison of Spirometry
(FEV₁) |
Mean ± SD |
t-
value |
p-
value |
|
Pre-Test |
64.87 ± 4.24 |
14.188 |
<0.0001 |
|
Post-Test |
|
||
Table 1represents the outcome measures of Spirometry
(FEV₁)in group A with a mean of 67.6 and SD
6.32. After the intervention post-test, the mean was 83.53, the SD was 4.21,
and the t-value was 11.418. Group B had a mean of 64.87 and SD 4.24 after the intervention post-test;
the mean was 74.80 and SD 3.32, and the t-value was 14.188.
Therefore, the P-value was 0.0001, indicating an extremely statistically
significant improvement in pulmonary function.
Figure 4: Mean Of Spirometry (FEV1) For Group A & Group B
Table 2: Mean
Of Dyspnoea
(BORG SCALE) For Group A & Group B
Descriptive
statics
|
GROUP
A |
Paired t- test |
||
|
Comparison Of Dyspnoea (Borg Scale) |
Mean ± SD |
t-
value |
p-
value |
|
Pre-Test |
4.53± 1.13 |
9.5394 |
<0.0001 |
|
Post-Test |
1.93± 0.7 |
||
|
GROUP
B |
Paired t- test |
||
|
Comparison Of Dyspnoea (Borg Scale) |
Mean ± SD |
t-
value |
p-
value |
|
Pre-Test |
7.8± 1.08 |
8.8764 |
<0.0001 |
|
Post-Test |
|
||
Table 2represents the outcome measures of Spirometry
(FEV₁)in group A with a mean of 4.53and SD 1.13. After the
intervention post-test, the mean was 1.93, the SD was 0.7, and the t-value was 9.5394. Group B
had a mean of 7.8 and SD 1.08
after the intervention post-test; the mean was 6.33 and SD 1.18, and the
t-value was 8.8764. Therefore, the P-value was 0.0001,
indicating an extremely statistically significant improvement in pulmonary
function
Figure 5: Post Analysis Comparison Between Group A & Group B
Table 3: Post Analysis Comparison Group A
&Group B
Descriptive
statics
|
|
Unpaired
Paired t- test |
||
|
Post analysis Comparison
Spirometry (FEV₁) |
Mean ± SD |
t-
value |
p-
valu e |
|
GROUP
A |
85.3± 4.21 |
6.3111 |
<0.0001 |
|
GROUP
B |
74.8± 3.32 |
||
|
|
Unpaired
Paired t- test |
||
|
Post analysis Comparison DYSPNOEA
(BORG SCALE) |
Mean ± SD |
t-
value |
p-
value |
|
GROUP
A |
1.93± 0.7 |
12.4411 |
<0.0001 |
|
GROUP
B |
|
||
Table 3 shows the post-test comparison between the two groups. The mean FEV₁ in Group A was 85.3 ± 4.21, whereas in Group B it was 74.8 ± 3.32, with P = 0.0001, indicating a highly statistically significant difference. Similarly, the mean dyspnea score measured using the Borg Scale was 1.93 ± 0.70 in Group A and 6.33 ± 1.18 in Group B, with p < 0.0001, showing a highly significant reduction in dyspnea in Group A compared to Group B.
Figure 6: Post Analysis Comparison Group-A
& Group-B
DISCUSSION
The current
study compared the effects of traditional physiotherapy exercises with
incentive spirometry on pulmonary function and dyspnea in patients who had
undergone CABG. The study's findings showed that after the therapies, lung
function and dyspnea levels significantly improved. Patients who performed
incentive spirometry along with physiotherapy exercises showed greater
improvement compared to those who performed conventional physiotherapy
exercises alone.
A common
complication following cardiac surgery is postoperative pulmonary dysfunction.
The reduction in pulmonary function observed after surgery may be attributed to
several factors, such as postoperative pain, reduced inspiratory effort,
fatigue, the development of atelectasis, and decreased coughing efforts. In
addition, surgical procedures such as lung retraction during cardiac surgery
and increased intra-thoracic fluid volume may also contribute to the reduction
in pulmonary function. Similar findings were reported by Barna Babik et al.
(2003), who showed that during thoracic surgery, the respiratory system's
mechanical characteristics significantly change.
In the
present study, spirometry values (FEV₁) showed significant improvement
following the intervention period in both groups. However, greater improvement
was observed in the group that performed incentive spirometry. This result is
in line with research by P. Agostini et al. (2007), which found that incentive
spirometry is a useful intervention for enhancing lung function and averting
pulmonary problems after thoracic surgery. Similarly, Jean N. Crowe et al.
(1997) added that incentive spirometry to postoperative pulmonary physiotherapy
would help high-risk patients experience fewer pulmonary problems following
CABG surgery.
The current
study's results also showed a decrease in dyspnea levels as determined by the
Borg scale after the intervention. These results are supported by the work of
Elisabeth Westerdahl et al. (2005), who reported that deep breathing exercises
after CABG surgery significantly improved pulmonary function and reduced
atelectasis. Furthermore, John C. Hall et al. (1996) reported that lung
expansion and incentive spirometry are effective in preventing postoperative
respiratory complications.
Early
postoperative respiratory physiotherapy plays a vital role in preventing
pulmonary complications and promoting recovery after cardiac surgery. According
to Rochelle Wynne et al. (2004), pulmonary treatments administered over an
extended period of time are advantageous in the treatment of pulmonary
dysfunction following surgery. Hulya Akdur et al. (2001) reported that
intensive postoperative physiotherapy programs improve pulmonary function,
reduce pulmonary complications, and shorten the duration of hospital stay.
However,
some previous studies have reported conflicting findings regarding the
effectiveness of incentive spirometry. For instance, a comprehensive review by
Tom J. Overend et al. (2001) found inadequate evidence to justify the routine
use of incentive spirometry in reducing pulmonary problems following cardiac or
abdominal surgery. Despite these findings, the present study demonstrated
significant improvements in pulmonary function and dyspnea scores with the use
of incentive spirometry.
Overall, this study's findings indicate that incentive
spirometry combined with conventional physiotherapy exercises may be beneficial
in improving pulmonary function and reducing dyspnea in postoperative CABG
patients. Regular practice of breathing exercises and lung expansion techniques
may help prevent postoperative pulmonary complications and promote faster
recovery.
CONCLUSION
The present study demonstrated that both conventional
physiotherapy and incentive spirometry exercises contributed to improvements in
pulmonary function and reduction of dyspnea in postoperative Coronary Artery
Bypass Grafting (CABG) patients. However, patients who received incentive
spirometry in addition to conventional physiotherapy showed greater improvement
in FEV₁ values and Borg dyspnea scores. These findings suggest that
incentive spirometry is an effective adjunct to conventional physiotherapy in
enhancing pulmonary function and reducing dyspnea following CABG surgery.
Therefore, the incorporation of incentive spirometry in postoperative
physiotherapy management may facilitate better respiratory recovery and help
minimize postoperative pulmonary complications.
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