Impact of lung expansion therapy using positive end-expiratory pressure in mechanically ventilated patients submitted to coronary artery bypass grafting

Abstract Objective: To evaluate the impact of different levels of positive end-expiratory pressure (PEEP) on gas exchange in patients undergoing coronary artery bypass grafting (CABG). Methods: A randomized clinical trial was conducted with patients undergoing CABG surgery. Patients were randomized into three groups: Group 10, PEEP of 10 cmH2O; Group 12, PEEP of 12 cmH2O; and Group 15, PEEP of 15 cmH2O. After the randomization, all patients underwent gas analysis at three moments: (1) before lung expansion therapy (LET); (2) 30 minutes after LET; and (3) one hour after extubation. Results: Sixty-six patients were studied, of which 61.7% were men, with mean age of 64 ± 8.9 years. Patients allocated to Group 15 showed a significant improvement in gas exchange comparing pre- and post-expansion values (239±21 vs. 301±19, P<0,001) and the increase was maintained after extubation (278±26). Despite the use of high levels of PEEP, no significant hemodynamic change was evidenced. Conclusion: It is concluded that high levels of PEEP (15 cmH2O) are beneficial for the improvement of gas exchange in patients undergoing CABG.

Neuroprotective effect of low mean arterial pressure on postoperative cognitive deficit attenuated by prolonged coronary artery bypass time: a meta-analysis

Abstract Introduction: The true influence of the low mean arterial pressure (low MAP) during coronary artery bypass grafting (CABG) on the development of postoperative cognitive deficit (POCD) remains controversial. We aimed to perform a meta-analysis and meta-regression to determine the effect of low MAP on POCD, as well as moderator variables between low MAP and POCD. Methods: The Web of Science, PubMed database, Scopus and the Cochrane Library database (up to June 2018) were searched and retrieved articles systematically reviewed. Only randomized controlled trials (RCTs) comparing maintenance of low MAP (<80 mmHg) and high MAP (>80 mmHg) during cardiopulmonary bypass (CPB) were included in our final review. Statistical analysis of the risk ratio (RR) and corresponding 95% confidence interval (CI) was used to report the overall effect. The overall effect and meta-regression analysis were done using Mantel-Haenszel risk ratio (MHRR) and the corresponding 95% confidence interval (CI). Results: A total of 731 patients in three RCTs were included in this study. POCD occurred in 6.4% of all cases. Maintenance of low MAP did not reduce the occurrence of POCD (MHRR 1.012 [95% CI 0.277-3.688]; Z=0.018; P=0.986; I2=66%). Shorter CPB time reduced the occurrence of POCD regardless of group assignment (MH log risk ratio -0.519 [95% CI -0.949 - -0.089]; Z= -2.367; P=0.017). Conclusion: POCD is a common event among CABG patients. The neuroprotective effect of low MAP on POCD was attenuated by the prolonged CPB time.

Acute response to aerobic exercise on autonomic cardiac control of patients in phase iii of a cardiovascular rehabilitation program following coronary artery bypass grafting

Abstract Objective: The aim of the present study was to investigate the acute response to aerobic exercise on autonomic cardiac control of patients undergoing coronary artery bypass grafting (CABG). Methods: The study sample consisted of eight patients (age: 58.6±7.7 years; body mass index: 26.7±3.5 kg.m2) who underwent a successful CABG (no complications during surgery and/or in the following weeks). To assess heart rate variability (HRV), participants remained in a supine position with a 30-degree head elevation for 20 minutes. Electrocardiographic signal (protocol with three derivations) was collected from 600 Hz sample rate to obtain beat-to-beat intervals (R-R interval). This assessment was performed before, after one hour and after 24 hours of the exercise session. All patients underwent a 35 minutes aerobic exercise session (AES) (low-moderate intensity) on the cycle ergometer. Results: Significant differences were found in the time domain, with positive changes in root mean square of successive RR interval differences (rMSSD) (ms) (parasympathetic component) (one [P=0.017] and 24 hours [P=0.007] post-session). In the frequency domain, we found a significant difference in high frequency (HF) (ms2) (parasympathetic component) (one hour [P=0.048] post-session). The low frequency (LF)/HF ratio (sympathetic and parasympathetic components with a predominance of the sympathetic component) reached statistical significance only 24 hours (P=0.018) post-session. Additionally, the largest effect size was observed only for the LF/HF ratio at one (d=-0.8) and 24 hours (d=-1.3) after one AES. Conclusion: The practice of (acute) aerobic exercise improved autonomic cardiac control in patients undergoing CABG.

Benefits of fasting abbreviation with carbohydrates and omega-3 infusion during cabg: a double-blind controlled randomized trial

Abstract Objective: To assess postoperative clinical data considering the association of preoperative fasting with carbohydrate (CHO) loading and intraoperative infusion of omega-3 polyunsaturated fatty acids (ω-3 PUFA). Methods: 57 patients undergoing coronary artery bypass grafting (CABG) were randomly assigned to receive 12.5% maltodextrin (200 mL, 2 h before anesthesia), (CHO, n=14); water (200 mL, 2 h before anesthesia), (control, n=14); 12.5% maltodextrin (200 mL, 2 h before anesthesia) plus intraoperative infusion of ω-3 PUFA (0.2 g/kg), (CHO+W3, n=15); or water (200 mL, 2 h before anesthesia) plus intraoperative infusion of ω-3 PUFA (0.2 g/kg), (W3, n=14). The need for vasoactive drugs was analyzed, in addition to postoperative inflammation and metabolic control. Results: There were two deaths (3.5%). Patients in CHO groups presented a lower incidence of hospital infection (RR=0.29, 95% CI 0.09-0.94; P=0.023), needed fewer vasoactive drugs during surgery and ICU stay (P<0.05); and had better blood glucose levels in the first six hours of recovery (P=0.015), requiring less exogenous insulin (P=0.018). Incidence of postoperative atrial fibrillation (POAF) varied significantly among groups (P=0.009). Subjects who receive ω-3 PUFA groups had fewer occurrences of POAF (RR=4.83, 95% CI 1.56-15.02; P=0.001). Patients in the W3 group had lower ultrasensitive-CRP levels at 36 h postoperatively (P=0.008). Interleukin-10 levels varied among groups (P=0.013), with the highest levels observed in the postoperative of patients who received intraoperative infusion of ω-3 PUFA (P=0.049). Conclusion: Fasting abbreviation with carbohydrate loading and intraoperative infusion of ω-3 PUFA is safe and supports faster postoperative recovery in patients undergoing on-pump CABG.

Effects of high-intensity inspiratory muscle training associated with aerobic exercise in patients undergoing cabg: randomized clinical trial

Abstract Objective: Evaluate the interaction between high-intensity inspiratory muscle training (IMT) and aerobic exercise on physical capacity, respiratory muscle strength, peripheral muscle strength, and quality of life of patients who underwent coronary artery bypass grafting (CABG). Methods: Twenty-four patients underwent CABG were randomized into two groups. During 36 sessions, one group received IMT associated with aerobic exercise and the other group received only aerobic exercise. Primary outcome was the distance in the six-minute walk distance (6MWD) test. Secondary outcomes included respiratory muscle strength, peripheral muscle strength, and quality of life. Measures were taken at the baseline, at the 12th session, the 24th session, and 36th session. Results: Baseline characteristics were similar between the groups. There was no statistically significant difference between the two groups in any outcome [6MWD - P=0.935; peak oxygen consumption (PeakVO2) - P=0.853; maximal inspiratory pressure (MIP) - P=0.243; maximal expiratory pressure (MEP) - P=0.268; sitting-rising test (SRT) - P=0.212], but there was interaction in MIP (P=0.000) and all outcomes improved in the two groups (6MWD - P=0.000; PeakVO2 - P=0.000; MIP - P=0.000; MEP - P=0.000; SRT - P=0.000). Conclusion: There was an improvement of all outcomes in both groups, but IMT was not able to provide additional benefits. The use of this combination should be used with caution to not generate higher costs in the rehabilitation process of these patients.

Methodological quality of randomized clinical trials of respiratory physiotherapy in coronary artery bypass grafting patients in the intensive care unit: a systematic review

Abstract Objective: To assess methodological quality of the randomized controlled trials of physiotherapy in patients undergoing coronary artery bypass grafting in the intensive care unit. Methods: The studies published until May 2015, in MEDLINE, Cochrane and PEDro were included. The primary outcome extracted was proper filling of the Cochrane Collaboration's tool's items and the secondary was suitability to the requirements of the CONSORT Statement and its extension. Results: From 807 studies identified, 39 were included. Most at CONSORT items showed a better adequacy after the statement's publication. Studies with positive outcomes presented better methodological quality. Conclusion: The methodological quality of the studies has been improving over the years. However, many aspects can still be better designed.

Modelo de cuidado de enfermería al paciente posoperatorio temprano de revascularización miocárdica / Nursing care model for taients in early postoperative of myocardlal revascularization

El desarrollo de modelos de cuidado es un punto fundamental de apoyo para el contexto y desarrollo de la práctica de enfermería. Una de las propuestas recientes es la planteada por Fawcett, que incluye tres componentes: teórico, estructural y funcional. Esta propuesta ha sido seleccionada para la construcción del presente Modelo, utilizando la metodología de Retroinducción en la lógica. Objetivo: Diseñar un modelo de cuidado de enfermería al paciente en el período posoperatorio temprano (48-96 h) de un injerto de bypass de arteria coronaria. Método: El componente teórico se basó en la teoría humanística de Paterson y Zderad, fortalecido con la antropología filosófica a la investigación científica. El componente estructural tuvo en cuenta los conceptos del metaparadigma de enfermería: persona, medio ambiente, salud y enfermería, así como los conceptos centrales del modelo: evento clínico que requiere cuidado de enfermería, situación que requiere cuidado de enfermería y paciente en posoperatorio temprano de revascularización miocárdica. Por último, el componente funcional incluyó una propuesta de atención desarrollada previamente. Estos resultados abren una nueva posibilidad para mejorar las condiciones del paciente durante el período postoperatorio temprano. Conclusión: Enfermería deberá continuar con el desarrollo de trabajos semejantes que aporten y contribuyan al enriquecimiento de su conocimiento propio.

The development of models of care is a fundamental point of support for the context and development of the nursing practice. One of the recent proposals is that posed by Fawcett, which includes three components: theoretical, structural and functional. This proposal has been selected for the implementation of this model, using Retroinduction logic methodology. Objective: To design a model of nursing care for patients in the early postoperative period (48-96 h) of a coronary artery bypass graft. The theoretical component was based on Paterson and Zderad's humanistic theory and strengthened by philosophical anthropology. The structural component took into account the concepts included in the Nursing metaparadigm: the person, the environment, health and nursing, as well as the central concepts of the model: clinical event requiring nursing care, situation requiring nursing care and early postoperative patient of myocardial revascularization. Finally, the functional component includes a care proposal previously developed. This proposal opens a new possibility of improving the conditions of patients during early postoperative period. In conclusion, Nursing should continue the development of similar activities that contribute and help enrich their own knowledge.

Inspiratory muscle training and functional capacity in patients undergoing cardiac surgery

Abstract Introduction: Cardiac surgery is a highly complex procedure which generates worsening of lung function and decreased inspiratory muscle strength. The inspiratory muscle training becomes effective for muscle strengthening and can improve functional capacity. Objective: To investigate the effect of inspiratory muscle training on functional capacity submaximal and inspiratory muscle strength in patients undergoing cardiac surgery. Methods: This is a clinical randomized controlled trial with patients undergoing cardiac surgery at Instituto Nobre de Cardiologia. Patients were divided into two groups: control group and training. Preoperatively, were assessed the maximum inspiratory pressure and the distance covered in a 6-minute walk test. From the third postoperative day, the control group was managed according to the routine of the unit while the training group underwent daily protocol of respiratory muscle training until the day of discharge. Results: 50 patients, 27 (54%) males were included, with a mean age of 56.7±13.9 years. After the analysis, the training group had significant increase in maximum inspiratory pressure (69.5±14.9 vs. 83.1±19.1 cmH2O, P=0.0073) and 6-minute walk test (422.4±102.8 vs. 502.4±112.8 m, P=0.0031). Conclusion: We conclude that inspiratory muscle training was effective in improving functional capacity submaximal and inspiratory muscle strength in this sample of patients undergoing cardiac surgery.

Clopidogrel use after myocardial revascularization: prevalence, predictors, and one-year survival rate

Abstract Introduction: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario. Objective: Identify predictors of clopidogrel following CABG. Methods: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG. Results: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032). Conclusion: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG.

High-Intensity Inspiratory Protocol Increases Heart Rate Variability in Myocardial Revascularization Patients

Abstract Objective: To evaluate heart rate variability during an inspiratory muscle endurance protocol at three different load levels [30%, 60% and 80% of maximal inspiratory pressure], in patients who had previously undergone coronary artery bypass grafting. Methods: Nineteen late postoperative myocardial revascularization patients participating in a cardiovascular rehabilitation program were studied. Maximal inspiratory pressure maneuvers were performed. An inspiratory muscle endurance protocol at 30%, 60% and 80% of maximal inspiratory pressure was applied for four minutes each, in random order. Heart rate and RR intervals were recorded and heart rate variability was analyzed by time (RMSSD-the mean of the standard deviations for all R-R intervals, and RMSM-root-mean square differences of successive R-R intervals) and frequency domains indices (high and low frequency) in normalized units. ANOVA for repeated measurements was used to compare heart rate variability indices and Student t-test was used to compare the maximal inspiratory pressure and maximal expiratory pressure values. Results: Heart rate increased during performance of maximal respiratory pressures maneuvers, and the maximal inspiratory pressure and maximal expiratory pressure mean values were significantly lower than predicted values (P <0.05). RMSSD increased significantly at 80% in relation to rest and 30% of maximal inspiratory pressure and RMSM decreased at 30% and 60% of maximal inspiratory pressure in relation to rest (P <0.05). Additionally, there was significant and progressive decrease in low frequency and increase in high frequency at 30%, 60% and 80% of maximal inspiratory pressure in relation to the resting condition. Conclusion: These results suggest that respiratory muscle training at high intensities can promote greater parasympathetic activity and it may confer important benefits during a rehabilitation program in post-coronary artery bypass grafting.

Alternative Physical Therapy Protocol Using a Cycle Ergometer During Hospital Rehabilitation of Coronary Artery Bypass Grafting: a Clinical Trial

ABSTRACT OBJECTIVE: To compare the efficacy of a cycle ergometer-based exercise program to a standard protocol on the increment of the maximum distance walked during the six-minute walk test in the postoperative rehabilitation of patients submitted to coronary artery bypass grafting. METHODS: A controlled clinical trial pilot, blinded to the outcome, enrolled subjects who underwent coronary artery bypass grafting in a hospital from Southern Brazil. Subjects were designated for the standard physical rehabilitation protocol or to an alternative cycle ergometer-based protocol through simple random sampling. The primary outcome was the difference in the maximum distance walked in the six-minute walk test before and after the allocated intervention. RESULTS: Twenty-four patients were included in the analysis, 10 in the standard protocol and 14 in the alternative protocol group. There was an increment in the maximum distance walked in both groups, and borderline superiority in the intervention group comparing to the control group (312.2vs. 249.7; P=0.06). CONCLUSION: There was an increase in the maximum distance walked in the alternative protocol compared to the standard protocol. Thus, it is postulated that the use of a cycle ergometer can be included in physical rehabilitation in the hospital phase of postoperative coronary artery bypass grafting. However, randomized studies with larger sample size should be conducted to assess the significance of these findings.

Effects of Resistance Exercise Applied Early After Coronary Artery Bypass Grafting: a Randomized Controlled Trial

ABSTRACT OBJECTIVE: To evaluate the effects of resistance exercise applied early after coronary artery bypass grafting. METHODS: It is a randomized controlled trial with 34 patients undergoing coronary artery bypass grafting between August 2013 and May 2014. Patients were randomized into two groups by simple draw: a control group (n=17), who received conventional physical therapy and an intervention group (n=17), who received, additionally, resistance exercise. Pulmonary function and functional capacity were evaluated in preoperative period and hospital discharge by spirometry and the six-minute walk test. For statistical analysis, we used the following tests: Shapiro-Wilk, Mann-Whitney, Student'st and Fisher's exact. Variables withP<0.05 were considered significant. RESULTS: Groups were homogeneous in terms of demographic, clinical and surgical variables. Resistance exercise exerted no effect on pulmonary function of intervention group compared to control group. However, intervention group maintained functional capacity at hospital discharge measured by percentage of predict distance in 6MWT (54.122.7% vs. 52.515.5%,P=0.42), while control group had a significant decrease (59.211.1% vs. 50.69.9%, P<0.016). CONCLUSION: Our results indicate that resistance exercise, applied early, may promote maintenance of functional capacity on coronary artery bypass grafting patients, having no impact on pulmonary function when compared to conventional physical therapy.

Short-term inspiratory muscle training potentiates the benefits of aerobic and resistance training in patients undergoing CABG in phase II cardiac rehabilitation program / Treinamento muscular inspiratório de curto prazo potencializa os benefícios do treinamento aeróbico e resistido em pacientes após CRM na fase II de programa de reabilitação cardíaca

AbstractObjective:To investigate the efficiency of short-term inspiratory muscle training program associated with combined aerobic and resistance exercise on respiratory muscle strength, functional capacity and quality of life in patients who underwent coronary artery bypass and are in the phase II cardiac rehabilitation program.Methods:A prospective, quasi-experimental study with 24 patients who underwent coronary artery bypass and were randomly assigned to two groups in the Phase II cardiac rehabilitation program: inspiratory muscle training program associated with combined training (aerobic and resistance) group (GCR + IMT, n=12) and combined training with respiratory exercises group (GCR, n=12), over a period of 12 weeks, with two sessions per week. Before and after intervention, the following measurements were obtained: maximal inspiratory and expiratory pressures (PImax and PEmax), peak oxygen consumption (peak VO2) and quality of life scores. Data were compared between pre- and post-intervention at baseline and the variation between the pre- and post-phase II cardiac rehabilitation program using the Student's t-test, except the categorical variables, which were compared using the Chi-square test. Values of P<0.05 were considered statistically significant.Results:Compared to GCR, the GCR + IMT group showed larger increments in PImax (P<0.001), PEmax (P<0.001), peak VO2 (P<0.001) and quality of life scores (P<0.001).Conclusion:The present study demonstrated that the addition of inspiratory muscle training, even when applied for a short period, may potentiate the effects of combined aerobic and resistance training, becoming a simple and inexpensive strategy for patients who underwent coronary artery bypass and are in phase II cardiac rehabilitation.

ResumoObjetivo:Avaliar os efeitos de um programa de treinamento muscular inspiratório em curto prazo associado ao exercício aeróbio e resistido na força muscular respiratória, capacidade funcional e qualidade de vida de pacientes submetidos à cirurgia de revascularização do miocárdio, na Fase II da Reabilitação Cardíaca.Métodos:Trata-se de um estudo quase-experimental, prospectivo, com amostra de 24 pacientes submetidos à cirurgia de revascularização do miocárdio alocados aleatoriamente para Fase II da Reabilitação Cardíaca em dois grupos: grupo de treinamento muscular inspiratório associado ao treinamento combinado (aeróbio e resistido) (GRC + TMI, n=12) e grupo treinamento combinado e exercícios respiratórios (GRC, n=12) durante um período de 12 semanas, com 2 sessões semanais. Antes e após a intervenção, as seguintes mensurações foram obtidas: pressão inspiratória e expiratória máxima (PImáx e PEmáx), consumo de oxigênio de pico (VO2pico) e escore de qualidade de vida. Os dados foram comparados entre o momento pré e pós-intervenção na linha de base e a variação entre o pré e pós-programa de reabilitação cardíaca com uso do teste t de Student, exceto as variáveis categóricas, que foram comparadas pelo teste de qui-quadrado. Foi considerado um P<0,05.Resultados:Comparado ao GRC, o GRC + TMI apresentou maior incremento tanto na PImáx (P<0,001) quanto na PEmáx (P<0,001), no VO2pico (P<0,001) e na qualidade de vida (P<0,001).Conclusão:Demonstrou-se que a adição do programa de treinamento muscular inspiratório, mesmo quando aplicada por um curto período, pode complementar os efeitos do exercício aeróbio combinado ao resistido, tornando-se uma estratégia benéfica para pacientes submetidos à cirurgia de revascularização do miocárdio na Fase II da reabilitação cardíaca.

Rehabilitación cardiaca luego de la cirugía de revascularización miocárdica / Cardiac rehabilitation after coronary artery bypass surgery

La cardiopatía isquémica representa la principal causa de muerte a nivel mundial con un incremento en la incidencia en las poblaciones más jóvenes. Hoy en día existen estrategias de revascularización para el manejo de la isquemia aguda y/o crónica del miocardio. Estas son del tipo percutáneas así como también quirúrgicas. Aunque logremos mejorar la vascularización miocárdica mediante estos métodos, el principal determinante para mantener la permeabilidad coronaria y de los bypass confeccionados es una adecuada prevención secundaria. En esto se centran las propuestas de rehabilitación cardiaca a nivel mundial. Aunque se ha publicado mucho sobre el rol de la rehabilitación cardiaca luego de la revascularización percutánea, existen pocos trabajos capaces de sintetizar la situación actual del la rehabilitación cardiaca en el paciente que recibe cirugía de revascularización coronaria. El objetivo del presente trabajo es revisar el efecto de la rehabilitación en el retorno laboral, supervivencia, capacidad funcional, depresión y ansiedad, así como comparar la rehabilitación centralizada vs. domiciliaria en esta población de pacientes.

Ischemic heart disease is the leading cause of death worldwide with an increase in the incidence in younger populations. Today revascularization strategies are capable of alleviating acute ischemia and/or chronic ischemia. These can be performed percutaneously or through surgery. Even if we improve myocardial perfusion by these methods, the main determinant in maintaining patency of coronary arteries and bypass is a correctly instituted secondary prevention. This is the main focus of cardiac rehabilitation proposals. Although much has been published about the role of cardiac rehabilitation after percutaneous revascularization, there is little work able to synthesize the current state of cardiac rehabilitation in patients undergoing coronary artery bypass surgery. The aim of this paper is to review the effect of rehabilitation in the return to work, survival, functional capacity, depression and anxiety, as well as compare centralized vs. home rehabilitation in this patient population.

Effects of different PEEP levels on respiratory mechanics and oxygenation after coronary artery bypass grafting / Efeitos de diferentes níveis de PEEP na mecânica respiratória e oxigenação após revascularização do miocárdio

OBJECTIVE: To compare the effects of different levels of positive end-expiratory pressure on respiratory mechanics and oxygenation indexes in the immediate postoperative period of coronary artery bypass grafting. METHODS: Randomized clinical trial in which 136 patients underwent coronary artery bypass grafting between January 2011 and March 2012 were divided into three groups and admitted to mechanical ventilation with different positive end-expiratory pressure levels: Group A, 5 cmH2O (n=44), Group B, 8 cmH2O (n=47) and Group C, 10 cmH2O (n=45). Data about respiratory mechanics were obtained from mechanical ventilator monitor and oxygenation indexes from arterial blood gas samples, collected twenty minutes after intensive care unit admission. Patients with chronic obstructive pulmonary disease and patients submitted to off-pump, emergency or combined operations were not included. For statistical analysis, we used Kruskal-Wallis, G and Chi-square tests, considering results significant when P<0.05. RESULTS: Groups were homogeneous in terms of demographic, clinical and surgical variables. Patients ventilated with positive end-expiratory pressure of 10 cmH2O (Group C) had best compliance (P=0.04) and airway resistance values, this, however, without statistical significance. They also had best oxygenation indexes, with statistical difference in all analyzed variables, and lower frequency of hypoxemia (P=0.03). CONCLUSION: Higher levels of positive end-expiratory pressure in immediate postoperative period of coronary artery bypass grafting improved pulmonary compliance values and increased oxygenation indexes, resulting in lower frequency of hypoxemia.

OBJETIVO: Comparar os efeitos de diferentes níveis de pressão expiratória positiva final na mecânica respiratória e nos índices de oxigenação no pós-operatório imediato de revascularização do miocárdio. MÉTODOS: Ensaio clínico randomizado no qual 136 pacientes submetidos à revascularização do miocárdio, entre janeiro de 2011 e março de 2012, foram distribuídos em três grupos e admitidos na ventilação mecânica com diferentes níveis de pressão expiratória positiva final: Grupo A, 5 cmH2O (n=44), Grupo B, 8 cmH2O (n=47) e Grupo C, 10 cmH2O (n=45), sendo os dados da mecânica respiratória obtidos do monitor do ventilador mecânico e os índices de oxigenação por meio de gasometria arterial coletada vinte minutos após a admissão na unidade de terapia intensiva. Não foram incluídos pacientes com doença pulmonar obstrutiva crônica, cirurgias associadas, de emergência ou sem circulação extracorpórea. Para análise estatística, empregaram-se os testes de Kruskal-Wallis, Teste G e Qui-quadrado, considerando os resultados significantes quando P<0,05. RESULTADOS: Os grupos apresentaram-se homogêneos em relação às variáveis demográficas, clínicas e cirúrgicas. Os pacientes ventilados com pressão expiratória positiva final de 10 cmH2O (Grupo C) apresentaram os melhores valores de complacência (P=0,04) e de resistência das vias aéreas, esta, porém sem significância estatística. Apresentaram, ainda, os melhores índices de oxigenação, com diferença estatística em todas as variáveis estudadas, além de menor frequência de hipoxemia (P=0,03). CONCLUSÃO: Níveis mais elevados de pressão expiratória positiva final no pós-operatório imediato de revascularização do miocárdio incrementaram os valores de complacência pulmonar e melhoraram os índices de oxigenação, resultando acarretando em menor frequência de hipoxemia.

The use of the virtual reality as intervention tool in the postoperative of cardiac surgery / O uso da realidade virtual como ferramenta complementar no pós-operatório de cirurgia cardíaca

INTRODUCTION: Cardiac surgery has been the intervention of choice in many cases of cardiovascular diseases. Susceptibility to postoperative complications, cardiac rehabilitation is indicated. Therapeutic resources, such as virtual reality has been helping the rehabilitational process. The aim of the study was to evaluate the use of virtual reality in the functional rehabilitation of patients in the postoperative period. METHODS: Patients were randomized into two groups, Virtual Reality (VRG, n = 30) and Control (CG, n = 30). The response to treatment was assessed through the functional independence measure (FIM), by the 6-minute walk test (6MWT) and the Nottingham Health Profile (NHP). Evaluations were performed preoperatively and postoperatively. RESULTS: On the first day after surgery, patients in both groups showed decreased functional performance. However, the VRG showed lower reduction (45.712.3) when compared to CG (35.0612.09, P<0.05) in first postoperative day, and no significant difference in performance on discharge day (P>0.05). In evaluating the NHP field, we observed a significant decrease in pain score at third assessment (P<0.05). These patients also had a higher energy level in the first evaluation (P<0.05). There were no differences with statistical significance for emotional reactions, physical ability, and social interaction. The length of stay was significantly shorter in patients of VRG (9.410.5 days vs. 12.2 1 0.9 days, P<0.05), which also had a higher 6MWD (319.9119.3 meters vs. 263.5115.4 meters, P<0.02). CONCLUSION: Adjunctive treatment with virtual reality demonstrated benefits, with better functional performance in patients undergoing cardiac surgery.

INTRODUÇÃO: A cirurgia cardíaca tem sido a intervenção de escolha em muitos casos de doenças cardiovasculares. Pela susceptibilidade a complicações pós-operatórias, a reabilitação cardíaca é indicada. Recursos terapêuticos, como a realidade virtual, tem favorecido o processo reabilitacional. O objetivo do estudo foi avaliar o uso da realidade virtual na reabilitação funcional de pacientes pós-cirurgia cardíaca. MÉTODOS: Os pacientes foram randomizados em dois grupos, Realidade Virtual (GRV, n=30) e Grupo Controle (GC, n=30). A resposta ao tratamento foi avaliada por meio do Questionário de Medida de Independência Funcional (MIF), Teste de caminhada de 6 minutos e do Perfil de Saúde de Nottingham (PSN). Os questionários foram aplicados no pré e pós-operatório. RESULTADOS: No primeiro dia de pós-operatório, os pacientes de ambos os grupos demonstraram diminuição do desempenho funcional. No entanto, essa perda foi menor no GRV (45,712,3) em relação ao GC (35,0612,09, P<0,05), sem diferença significativa no momento da alta hospitalar (P>0,05). Na avaliação do PSN, foi observada menor intensidade da dor no terceiro momento de avaliação no GRV (P<0,05). Esses pacientes também apresentaram maior nível de energia na primeira avaliação (P<0,05). Não foram encontradas diferenças com significância estatística para reações emocionais, habilidade física e interação social. O tempo de internação foi significativamente menor nos pacientes do GRV (P<0,05), que também apresentaram maior distância percorrida no TC6 (319,9119,3 metros vs. 263,5115,4 metros, P<0,02). CONCLUSÃO: O tratamento com a realidade virtual foi eficaz em proporcionar melhor desempenho funcional pós-operatório.

Treinamento muscular melhora o volume corrente e a capacidade vital no pós-operatório de revascularização do miocárdio / Inspiratory muscle training improves tidal volume and vital capacity after CABG surgery

OBJETIVO: Avaliar a função pulmonar e força da musculatura respiratória no período pós-operatório e verificar o efeito do treinamento muscular inspiratório sobre as medidas de desempenho da musculatura respiratória em pacientes submetidos à revascularização do miocárdio. MÉTODOS: Estudo randomizado, incluindo 47 pacientes submetidos à revascularização do miocárdio com circulação extracorpórea. Os pacientes foram divididos em grupo controle (GC), 24 pacientes, e grupo estudo (GE) 23 pacientes, com idade média de 66,33 ± 10,20 anos e 61,83 ± 8,61 anos, respectivamente. O GE foi submetido à fisioterapia convencional e ao treinamento muscular inspiratório com threshold® IMT e o GC à fisioterapia convencional. Foram comparadas as pressões respiratórias máximas (Pimáx e Pemáx), volume corrente (VC), capacidade vital (CV) e pico de fluxo expiratório (Peak Flow) no pré-operatório (Pré-OP), 1º e 3º dias de pós-operatório (PO1) e (PO3). RESULTADOS: Observou-se redução significativa em todas as variáveis mensuradas no PO1, quando comparadas ao pré-operatório, nos dois grupos estudados, Pimáx (P<0,0001), Pemáx (P<0,0001), VC: GE (P<0,0004) e GC: (P< 0,0001) e CV GE: (P<0,0001) e GC: (P<0,0001) e peak flow (P<0,0001). No PO3, o GE apresentou em comparação ao GC, maior valor de CV, GE 1230,4 ± 477,86 ml vs. GC 919,17 ± 394,47 ml (P= 0,0222) e VC GE 608,09 ± 178,24 ml vs. GC 506,96 ± 168,31 ml (P=0,0490). CONCLUSÃO: Pacientes submetidos à cirurgia cardíaca sofrem redução da CV e da força muscular respiratória após a cirurgia. O treinamento muscular realizado foi eficaz em recuperar o VC e a CV no PO3, no grupo treinado.

OBJECTIVE: To evaluate lung function and respiratory muscle strength in the postoperative period and investigate the effect of inspiratory muscle training on measures of respiratory muscle performance in patients undergoing coronary artery bypass grafting. METHODS: A randomized study with 47 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. They were divided into study group (SG) 23 patients and control group (CG) 24 patients, mean age 61.83 ± 8.61 and 66.33 ± 10.20 years, EuroSCORE SG 0.71 ± 0.0018 and CG 0.76 ± 0.0029, respectively. The study group underwent physical therapy and inspiratory muscle training with threshold IMT® and CG underwent conventional physiotherapy. We compared the maximal respiratory pressures (MIP and MEP), tidal volume (TV), vital capacity (VC) and peak expiratory flow (peak flow) preoperatively (Pre-OP), 1st (PO1) and 3rd (PO3) postoperative day. RESULTS: There was a significant reduction in all variables measured on PO1 compared to preoperative values in both groups, MIP (P <0.0001), MEP (P <0.0001), TV SG (P <0.0004) and CG (P <0.0001) and VC SG (P <0.0001) and CG (P <0.0001) and peak flow (P <0.0001). At PO3, SG presented higher value of VC, GE 1230.4 ± 477.86 ml vs. GC 919.17 ± 394.47 ml (P=0.0222) and TV SG 608.09 ± 178.24 ml vs. CG 506.96 ± 168.31 ml (P= 0.0490). CONCLUSION: Patients undergoing cardiac surgery experience reduced ventilatory capacity and respiratory muscle strength after surgery. Muscle training was performed to retrieve TV and VC in the PO3, in the trained group.

Teste de caminhada de seis minutos como ferramenta para avaliar a qualidade de vida em pacientes submetidos à cirurgia de revascularização miocárdica / Six-minute walk test as a tool for assessing the quality of life in patients undergoing coronary artery bypass grafting surgery

OBJETIVO: Avaliar a utilidade do teste de caminhada de seis minutos como indicador prognóstico de qualidade de vida em pacientes submetidos a revascularização do miocárdio. MÉTODO: Estudo prospectivo observacional em pacientes submetidos a operação de revascularização do miocárdio. Foram avaliadas as características clínicas, teste de caminhada de seis minutos (TC6) e questionário para avaliação de qualidade de vida, o questionário SF-36. Os pacientes foram avaliados no pré-operatório e divididos em dois grupos, conforme a distância percorrida no TC6: grupo que caminhou mais de 350 metros e grupo que caminhou menos de 350 metros. RESULTADOS: Foram incluídos no estudo 87 pacientes. A idade média semelhante em ambos os grupos (59 ± 9,5 anos vs. 61 ± 9,3 anos; P = 0,24). Os pacientes do grupo > 350 metros caminharam mais no TC6 após dois meses de operação (436 ± 78 metros vs. 348 ± 87 metros; P<0,01) quando comparado ao grupo < 350 metros. Observamos que a qualidade de vida era inferior no grupo < 350 metros em relação ao grupo > 350 metros, no período pré-operatório, nos domínios: capacidade funcional, aspectos físicos, estado geral de saúde, vitalidade e aspectos sociais. A qualidade de vida melhorou após dois meses, em ambos os grupos. CONCLUSÕES: O TC6 no pré-operatório tem correlação com a qualidade de vida após dois meses de revascularização do miocárdio. A qualidade de vida melhorou de forma geral em todos pacientes, sendo maior a melhora da qualidade de vida naqueles que caminharam menos que 350 metros no pré-operatório.

OBJECTIVE: To assess the quality of life in patients undergoing myocardial revascularization using the six-minute walk test. METHODS: Prospective observational study with patients who undergoing CABG. The clinical variables, the sixminute walk test, and the SF-36 test were recorded. The patients were assessed at the preoperative time and at 2 months of postoperative period. According their six-minute walk test results, the patients were divided into two groups: group walked more than 350 meters (> 350 meters Group) and the group walked less than 350 meters (< 350 meters Group) at the preoperative time. RESULTS: Eight-seven patients were included. Age was comparable in both groups (59 ± 9.5 years vs. 61 ± 9.3 years; respectively, P = 0.24). The group walked > 350 meters distance was higher than the < 350 meters group after 2 months of operation (436 ± 78 meters vs. 348 ± 87 meters; P <0.01). The quality of life was lower in the < 350 meters group compared to the > 350 meters group in the preoperative period in the following domains: functional capabilities, limitations due to physical aspects, overall health feelings, vitality, and social aspects. Quality of life improved after two months in both groups. CONCLUSIONS: The six-minute walk test at the preoperative time is associated with the quality of life after two months of coronary artery bypass grafting. In overall, quality of life has improved in all patients. The improvement in the quality of life was greater in those patients who walked distances lower than 350 meters at the preoperative time.

Avaliação da ventilação não-invasiva com dois níveis de pressão positiva nas vias aéreas após cirurgia cardíaca / Assessment of noninvasive ventilation with two levels of positive airway pressure in patients after cardiac surgery

INTRODUÇÃO: A aplicação de ventilação por dois níveis de pressão positiva (BiPAP®) associada à fisioterapia respiratória convencional (FRC) no pós-operatório (PO) imediato de cirurgia cardíaca pode contribuir para a diminuição das complicações pulmonares. OBJETIVO: Avaliar a segurança e a adesão da aplicação preventiva do BiPAP® associado a FRC no PO imediato de revascularização do miocárdio. MÉTODOS: Vinte e seis pacientes submetidos a revascularização do miocárdio foram aleatoriamente alocados. O Grupo Controle (GC) foi tratado com FRC, o Grupo BiPAP (GB) foi submetido a 30 minutos de BiPAP®, duas vezes ao dia, associado à FRC. A FRC foi realizada em ambos os grupos, duas vezes ao dia. Todos os pacientes foram avaliados quanto: capacidade vital, permeabilidade das vias aéreas, pressões respiratórias máximas, saturação de oxigênio, frequência cardíaca, frequência respiratória, volume minuto, volume corrente, pressões arteriais sistólica e diastólica. As avaliações foram realizadas durante a internação no pré-operatório, imediatamente após a extubação, e na 24ª e 48ª horas após extubação. RESULTADOS: No GC, 61,5 por cento dos pacientes tiveram algum grau de atelectasias, no GB, 54 por cento (P=0,691). A capacidade vital foi estatisticamente maior no GB no PO (P<0,015). Todos os outros parâmetros de ventilometria, gasometria, manovacuometria e hemodinâmicos foram semelhantes entre os grupos. CONCLUSÃO: A cirurgia de revascularização do miocárdio leva à degradação da função respiratória no PO, e a aplicação da ventilação com pressão positiva (BiPAP®) pode ser benéfica para reestabelecer a função pulmonar mais rapidamente, principalmente a capacidade vital, de forma segura, sendo bem aceita pelos paciente, devido ao maior conforto em relação à sensação de dor durante a execução da fisioterapia respiratória.

INTRODUCTION: The application of two levels of ventilation by positive pressure (BiPAP®) associated with conventional respiratory therapy (CRT) in postoperative periord of cardiac surgery may contribute to reduction of pulmonary complications. OBJECTIVES: To evaluate the safety and compliance of preventive application of BiPAP® CRT associated with immediate postoperative myocardial revascularization. METHODS: 26 patients undergoing coronary artery bypass grafting were randomly allocated in one of the groups. Patients of the Control Group (CG) were treated only with conventional respiratory therapy, compared to BiPAP group (BG) (in addition to conventional respiratory therapy the patients were subjected to 30 minutes of ventilation by two levels twice a day). The conventional respiratory therapy was held in both groups, twice a day. All patients were evaluated for vital capacity, airway permeability, maximal respiratory pressures, oxygen saturation, heart rate, respiratory frequency, Volume Minute, tidal volume, systolic and diastolic blood pressure. Evaluations were performed during hospitalization preoperatively, immediately after extubation, 24h and 48h after extubation. RESULTS: In CG 61.5 percent of patients had some degree of atelectasias, in comparison to 54 percent of BG (P=0.691). The vital capacity was higher in the GB postoperatively (P<0.015). All the other ventilometric, gasometric, hemodynamic and manometric parameters were similar between groups. CONCLUSION: Coronary artery bypass grafting leads to deterioration of respiratory function postoperatively, and the application of positive pressure ventilation (BiPAP®) may be beneficial to restore lung function more quickly, especially vital capacity, safely, and well accepted by patients due to greater comfort with the sensation of pain during the execution of respiratory therapy.

Estimulação elétrica nervosa transcutânea após cirurgia de revascularização miocárdica / Transcutaneous electrical nerve stimulation after coronary artery bypass graft surgery

INTRODUÇÃO: Após a cirurgia cardíaca, os pacientes apresentam limitação na força muscular respiratória, o que favorece a instalação de complicações pulmonares. OBJETIVO: Analisar a eficácia da estimulação elétrica nervosa transcutânea sobre o processo doloroso e força muscular respiratória em pacientes submetidos à cirurgia de revascularização do miocárdio (CRM). MÉTODOS: Foram inclusos pacientes em pós-operatório de CRM por meio de esternotomia, com uso de circulação extracorpórea, anestesia geral, sem estar sob efeito de bloqueio neuromuscular, uso de drenos de tórax e mediastino, extubados até 6 horas pós-procedimento e apresentando índice igual ou superior a três na escala analógica visual da dor (EVA), estando no primeiro dia de pós-operatório (1º DPO). Foram recrutados 20 pacientes, divididos em dois grupos, sem predomínio de sexo: Grupo Controle (n=10), que recebeu terapia analgésica mais fisioterapia; e Grupo TENS, que recebeu terapia analgésica, fisioterapia e TENS. A TENS foi aplicada por 30 minutos, três vezes ao dia, num intervalo de 3 horas cada aplicação. RESULTADOS: Para o grau de dor, houve uma média inicial e final, respectivamente, de 7,0 e 1,0 para o Grupo TENS e 7,0 e 8,0 para o Grupo Controle. Para a Pimáx, a média inicial e final foi de, respectivamente, -102,5 cmH2O e -141,17 cmH2O para o Grupo TENS e -97,0 cmH2O e -100,3 cmH2O para o Controle. Quanto a Pemáx, a média inicial e final foi de, respectivamente, 63 cmH2O e 125 cmH2O para o Grupo TENS e 55,3 cmH2O e 53,2 cmH2O para o Grupo Controle. CONCLUSÃO: A TENS demonstrou eficácia significativa na redução da algia e no aumento das forças musculares respiratórias no 1º DPO de CRM.

INTRODUCTION: After cardiac surgery, patients have a limitation in respiratory muscle strength, which favors the appearing of pulmonary complications. OBJECTIVE: To evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) on the painful process and respiratory muscle strength in patients undergoing coronary artery bypass graft (CABG). METHODS: The study included patients after on-pump CABG through sternotomy, general anesthesia, without being under the influence of neuromuscular blockade, with use of chest and mediastinal tubes, and extubation within 6 hours after the procedure and presenting index equal to or greater than three visual analog scale (VAS) of pain being on the first day after surgery. We recruited 20 patients divided into two groups with no predominance of sex: the control group (n = 10), who received more physiotherapy analgesic therapy, and TENS group received analgesic therapy, physiotherapy and TENS. The TENS was applied for 30 minutes, three times a day, a 3-hour period each application. RESULTS: For the degree of pain, there was an average start and end, respectively, 7.0 / 1.0 for the TENS group and 7.0 / 8.0 for the control group. For inspiratory muscle strength, - 102.5 cmH2O / - 141.17 cm H2O to the TENS group and - 97.0 cmH2O / - 100.3 cm H2O for control. The expiratory muscle strength, 63cmH2O/125 cmH2O for the TENS group and 55.3 cmH2O/53, 2 cmH2O for the control group. CONCLUSIONS: TENS has shown significant effectiveness in reducing pain, and the increase in respiratory muscle strength at first-day after CABG surgery.