Abstracts
Objective:
To evaluate whether the application of bilevel positive airway pressure in the postoperative period of bariatric surgery might be more effective in restoring lung volume and capacity and thoracic mobility than the separate application of expiratory and inspiratory positive pressure.
Method:
Sixty morbidly obese adult subjects who were hospitalized for bariatric surgery and met the predefined inclusion criteria were evaluated. The pulmonary function and thoracic mobility were preoperatively assessed by spirometry and cirtometry and reevaluated on the 1st postoperative day. After preoperative evaluation, the subjects were randomized and allocated into groups: EPAP Group (n=20), IPPB Group (n=20) and BIPAP Group (n=20), then received the corresponding intervention: positive expiratory pressure (EPAP), inspiratory positive pressure breathing (IPPB) or bilevel inspiratory positive airway pressure (BIPAP), in 6 sets of 15 breaths or 30 minutes twice a day in the immediate postoperative period and on the 1st postoperative day, in addition to conventional physical therapy.
Results:
There was a significant postoperative reduction in spirometric variables (p<0.05), regardless of the technique used, with no significant difference among the techniques (p>0.05). Thoracic mobility was preserved only in group BIPAP (p>0.05), but no significant difference was found in the comparison among groups (p>0.05).
Conclusion:
The application of positive pressure does not seem to be effective in restoring lung function after bariatric surgery, but the use of bilevel positive pressure can preserve thoracic mobility, although this technique was not superior to the other techniques.
bariatric surgery; physical therapy specialty; spirometry
Objetivo:
Avaliar se a aplicação de dois níveis de pressão positiva nas vias aéreas no pós-operatório de cirurgia bariátrica pode ser mais efetiva do que quando aplicadas pressões positivas expiratória e inspiratória separadamente na restauração dos volumes e capacidades pulmonares e na mobilidade torácica.
Método:
Foram avaliadas 60 voluntárias adultas, obesas mórbidas, internadas para realização da cirurgia bariátrica. Afunção pulmonar e a mobilidade torácica foram avaliadas por meio da espirometria e da cirtometria no pré-operatório e reavaliadas no primeiro pós-operatório. Após a avaliação pré-operatória, as voluntárias foram randomizadas e alocadas nos grupos G EPAP (n=20), G RPPI (n=20) e G BIPAP (n=20) e então receberam a intervenção proposta, pressão positiva expiratória nas vias aéreas (EPAP), respiração por pressão positiva inspiratória (RPPI) ou pressão positiva binível nas vias aéreas (BIPAP), em sessões de seis séries de 15 respirações ou de 30 minutos, duas vezes ao dia no pós-operatório imediato e no primeiro pós-operatório, além do tratamento fisioterapêutico convencional.
Resultados:
Houve redução significativa das variáveis espirométricas no pós-operatório (p<0,05), independente do recurso utilizado, não havendo diferença significativa entre as técnicas (p>0,05), e preservação da mobilidade torácica somente nas voluntárias do grupo BIPAP (p>0,05), porém sem diferença nas comparações entre os grupos (p>0,05).
Conclusão:
A aplicação de pressão positiva parece não ser efetiva na restauração da função pulmonar no pós-operatório de cirurgia bariátrica, porém a aplicação de dois níveis de pressão positiva pode preservar a mobilidade torácica, embora não tenha demonstrado superioridade em relação às outras técnicas.
cirurgia bariátrica; fisioterapia; espirometria
Introduction
In obese individuals, a combination of factors such as reduced lung and chest wall
compliance, increased lung elastic resistance and exaggerated distension of the
diaphragm may affect the respiratory system, resulting in decreased lung volumes and
capacities. This condition is especially important considering that respiratory changes
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Bariatric surgery may impair the lung function during the postoperative period,
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. The change in the pulmonary mechanics generates a
restrictive pattern with reduced vital capacity (VC) and functional residual capacity
(FRC). The VC and forced vital capacity (FVC) are usually reduced in the postoperative
period to approximately 40-50% of the preoperative values, which persists for at least
10 to 14 days44. Ferreira FR, Moreira FB, Parreira VF. Ventilação não invasiva no
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consequent reflex inhibition of the phrenic nerve and postoperative pain99. Vassilakopoulos T, Mastora Z, Katsaounou P, Doukas G, Klimopoulos S,
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, which peaks between two to eight hours after
surgery1010. Romanini W, Muller AP, Carvalho KA, Olandoski M, Faria-Neto JR,
Mendes FL, et al. Os efeitos da pressão positiva intermitente e do incentivador
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and triggers a reduction in lung
volumes and capacities, changes in the ventilation/perfusion ratio, decreased
thoracoabdominal expansion22. Koenig SM. Pulmonary complications of obesity. Am J Med Sci.
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, inefficiency in the
airway defense mechanisms, such as cough, and depression of the immune system, factors
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, severe hypoxemia, pulmonary embolism,
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,
1111. Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic
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,.
Some evidence suggests that for these reasons, pre- and postoperative physical therapy
follow-up of patients who undergo bariatric surgery is extremely important for
preventing complications inherent to the surgical process and for recovering lung
function1313. Tenório LH, de Lima AM, Brasileiro-Santos MS. Intervenção da
fisioterapia respiratória na função pulmonar de indivíduos obesos submetidos a
cirurgia bariátrica. Uma revisão. Rev Port Pneumol. 2010;16(2):307-14. PMid:20437006. , whereas It has been suggested that
the use of respiratory physical therapy in the postoperative routine is not justified
because few clinical trials show its prophylactic effectiveness1414. Pasquina P, Tramèr MR, Granier JM, Walder B. Respiratory
physiotherapy to prevent pulmonary complications after abdominal surgery: a
systematic review. Chest. 2006;130(6):1887-99. http://dx.doi.org/10.1378/
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concluded that, due to the poor quality of the available studies, there was still
uncertainty regarding the value of physical therapy routinely performed to prevent
pulmonary complications after abdominal surgery. Thus, well-designed studies on the
subject that may contribute to establishing more effective physical therapy procedures
to be performed in the postoperative period of abdominal surgery are needed1616. Weindler J, Kiefer RT. The efficacy of postoperative incentive
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.
Among the respiratory physical therapy techniques that aim to preserve or improve lung
function, promoting growth or maintenance of lung volumes and capacities, are devices
with positive airway pressure, which can be used in the postoperative period of
thoracoabdominal surgery to prevent or treat hypoxic respiratory failure, improve
arterial oxygenation, reduce atelectasis and decrease respiratory work without
generating increased incidence of fistulas or dehiscence of surgical anastomoses1818. Pessoa KC, Araújo GF, Pinheiro AN, Ramos MR, Maia SC. Noninvasive
ventilation in the immediate postoperative of gastrojejunal derivation with Roux-en-Y
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M, et al. Continuous positive airway pressure via the Boussignac system immediately
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The use of positive airway pressure has been shown to be effective in restoring the FRC
and promotes changes in other lung volumes and capacities, such as inspiratory reserve
volume (IRV), expiratory reserve volume (ERV) and FVC. However, there is controversy
regarding the maintenance produced by positive airway pressure44. Ferreira FR, Moreira FB, Parreira VF. Ventilação não invasiva no
pós-operatório de cirurgias abdominais e cardíacas -revisão da literatura. Rev Bras
Fisioter. 2002;6(2):47-54. . EPAP (Expiratory Positive Airway Pressure), BIPAP (Bilevel
Positive Airway Pressure) and intermittent positive pressure breathing (IPPB) are
techniques using positive airway pressure aimed at lung re-expansion, preventing
premature airway collapse and thus preventing pulmonary atelectasis, and may contribute
to the reduction in postoperative complications of the pulmonary restrictive syndrome
associated with obesity2222. Fagevik Olsén M, Hahn I, Nordgren S, Lönroth H, Lundholm K.
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2424. Nava S, Ambrosino N, Rubini F, Fracchia C, Rampulla C, Torri G, et
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. The EPAP technique uses only positive
end-expiratory pressure (PEEP), reducing the expiratory flow2222. Fagevik Olsén M, Hahn I, Nordgren S, Lönroth H, Lundholm K.
Randomized controlled trial of prophylactic chest physiotherapy in major abdominal
surgery. Br J Surg. 1997;84(11):1535-8. http://dx.doi.org/10.1002/ bjs.1800841111.
PMid:9393272.
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, whereas BIPAP combines PEEP with the benefits of support
pressure, and they can be adjusted to keep the lung expanded throughout the respiratory
cycle, promoting lung inflation2323. Joris JL, Sottiaux TM, Chiche JD, Desaive CJ, Lamy ML. Effect of
bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative
pulmonary restrictive syndrome in obese patients undergoing gastroplasty. Chest.
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,
2424. Nava S, Ambrosino N, Rubini F, Fracchia C, Rampulla C, Torri G, et
al. Effect of nasal pressure support ventilation and external PEEP on diaphragmatic
activity in patients with severe stable COPD. Chest. 1993;103(1):143-50.
http://dx.doi.org/10.1378/chest.103.1.143. PMid:8417869
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. The IPPB technique allows, in addition to
alveolar recruitment, the synchronization of inspiratory time, aiming to reduce the
respiratory effort and resume normal lung function1010. Romanini W, Muller AP, Carvalho KA, Olandoski M, Faria-Neto JR,
Mendes FL, et al. Os efeitos da pressão positiva intermitente e do incentivador
respiratório no pós-operatório de revascularização miocárdica. Arq Bras Cardiol.
2007;89(2):105-10. http://dx.doi.org/10.1590/ S0066-782X2007001400006. PMid:17874015.
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.
Considering that the obese population may have restrictive lung characteristics, which may be even more pronounced during the abdominal postoperative period, and that positive airway pressure techniques may be able to restore lung function and chest mobility differently, in this study, three respiratory techniques were investigated: the IPPB technique which favors the inspiratory capacity (IC) by promoting positive airway pressure only in the inspiration phase; the positive expiratory pressure generated by EPAP which, mainly favors the FRC in an attempt to promote the maintenance or recovery of ERV; and, BIPAP, which provides positive pressure in both phases of the respiratory cycle, and tends to favor VC, encompassing the benefits of the other two techniques. Thus, the objective of this study was to test whether the application of bilevel positive airway pressure during the postoperative period of bariatric surgery would be more effective than applying inspiratory and expiratory positive pressures separately in restoring lung volumes, lung capacities, and thoracic mobility.
Method
Experimental design
This clinical trial was developed respecting the rules of conduct in experimental research with humans after being approved by the Ethics in Research Committee of the Universidade Metodista de Piracicaba (UNIMEP), Piracicaba, São Paulo, Brazil, under approval no. 89/12 and registered at Clinicaltrials.gov under identifier NCT01872663.
The sample size calculation was based on a pilot study, in which the mean (0.13) and standard deviation (0.17) of the differences between pre- and postoperative ERV values were obtained using the ANOVA test in the BioEstat 5.3 application, adopting a statistical power of 90% and an alpha of 0.05. Thus, the number of 17 volunteers per group was determined.
Participants
In total, 68 morbidly obese adult women admitted to a hospital in the city of
Piracicaba, São Paulo, Brazil for elective bariatric surgery by the responsible
physician, with a prescription for respiratory physical therapy. The subjects had to
meet the following inclusion criteria: body mass index (BMI) between 40 and 55
kg/m22. Koenig SM. Pulmonary complications of obesity. Am J Med Sci.
2001;321(4):249-79. http://dx.doi.org/10.1097/00000441-200104000-00006.
PMid:11307867.
https://doi.org/10.1097/00000441-2001040...
, aged between 25 and 55 years,
candidates for Roux-en-Y gastric bypass bariatric surgery by laparotomy, nonsmokers,
with chest x-ray and preoperative pulmonary function test within the parameters of
normality and who signed the consent form. Subjects with asthma, chronic obstructive
pulmonary disease (COPD) or obstructive sleep apnea (OSA) syndrome were excluded, as
were subjects who presented with hemodynamic instability, hospital stay longer than
three days, presence of postoperative complications or an inability to understand or
refusal to perform the evaluations or the proposed treatment.
Procedures
The lung function and chest mobility of the patients were evaluated preoperatively, immediately after hospital admission, and reassessed on the first postoperative day, after the physical therapy sessions were completed. The investigator who conducted the assessments was blind to the treatment received, and the investigator who performed the treatments was blind to the assessments. During the preoperative evaluation, the presence of comorbidities such as systemic arterial hypertension (SAH), diabetes mellitus and dyslipidemia was recorded.
After the preoperative evaluation, the 68 volunteers were allocated into three groups using a block randomization process in Microsoft(r) Excel 2007 conducted by an investigator blind to both the clinical data and the volunteers' assessment. The groups were as follows: Group EPAP (Expiratory Positive Airway Pressure), Group IPPB (Intermittent Positive Pressure Breathing) and Group BIPAP (Bilevel Positive Airway Pressure). During the application of interventions, eight subjects were excluded. In the end, a total of 60 subjects comprised three groups of 20 (Figure 1).
Flow diagram of the study sample. EPAP: Expiratory Positive Airway Pressure; IPPB: Intermittent Positive Pressure Breathing; BIPAP: Bilevel Positive Airway Pressure. PO - Post Operatively.
All subjects received the proposed intervention twice a day in the immediate
postoperative period and on the first postoperative day (1st PO); in
combination with positive airway pressure therapy. All subjects also received
conventional physical therapy, also performed twice a day postoperatively, consisting
of exercises with diaphragmatic breathing, deep inspirations, fractionated
inspirations, breathing exercises associated with upper limb movement2525. Costa D, Forti EMP, Barbalho-Moulim MC, Rasera-Junior I. Study on
pulmonary volumes and thoracoabdominal mobility in morbidly obese women undergoing
bariatric surgery, treated with two different physical therapy methods. Rev Bras
Fisioter. 2009;13(4):294-301. http:// dx.doi.org/10.1590/S1413-35552009005000041.
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, and incentive spirometer. One series with 15 repetitions was developed
for each exercise, with a mean duration of 20 to 30 minutes, in addition to exercises
to prevent deep vein thrombosis and to promote ambulation.
Lung function was assessed by spirometry of the subjects, performed using a
microQuark computerized ultrasonic spirometer, USB model (Cosmed(r), Rome,
Italy). The slow vital capacity (SVC) maneuver was performed according to the
guidelines of the American Thoracic Society (ATS) and the European Respiratory
Society (ERS)2626. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A,
et al. Standardisation of spirometry. Eur Respir J. 2005;26(2):319-38.
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and repeated until three
acceptable and two reproducible curves were obtained, not exceeding more than eight
attempts. To calculate the predicted values, the equation proposed by Pereira et
al.2727. Pereira CAC, Barreto SP, Simões JG, Pereira FWL, Gerstler JG,
Nakatani J. Valores de referência para espirometria em uma amostra da população
brasileira adulta. J Pneumol. 1992;18:10-22. for the Brazilian population was
used, and the values of SVC, ERV, IRV and tidal volume (TV) were selected according
to the recommendations of Pereira2828. Pereira CAC. Directives for pulmonary function tests. J Pneumol.
2002;28(3):1-82. . The IC
values were calculated from the sum of IRV and TV.
The thoracic mobility evaluation was performed by cirtometry at the axillary and
xiphoid levels by the same researcher, using a tape measure scaled in centimeters,
measuring the circumferences after a maximal inspiration and after a maximal
expiration while the subjects were in a standing position. Three measurements were
repeated at each level, and the maximum value obtained during inspiration and the
minimum value obtained during expiration were computed. The absolute difference
between these values was considered to represent the thoracic mobility for each
level2525. Costa D, Forti EMP, Barbalho-Moulim MC, Rasera-Junior I. Study on
pulmonary volumes and thoracoabdominal mobility in morbidly obese women undergoing
bariatric surgery, treated with two different physical therapy methods. Rev Bras
Fisioter. 2009;13(4):294-301. http:// dx.doi.org/10.1590/S1413-35552009005000041.
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,
2929. Jamami M, Pires VA, Oishi J, Costa D. Efeitos da intervenção
fisioterápica na reabilitação pulmonar de pacientes com doença pulmonar obstrutiva
crônica (DPOC). Rev Fisioter Univ São Paulo. 1999;6(2):140-53. .
To minimize the interference of pain on postoperative assessments, before initiating
the assessments, the subjects rated their pain level using a Visual Analogue Scale
(VAS)3030. Scott J, Huskisson EC. Graphic representation of pain. Pain.
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3131. Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA.
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. When the pain was rated above 4, the
nursing staff was requested to administer an analgesic with dipyrone, according to
medical prescription, and the pain was then scored again after 30 minutes before the
revaluation was started.
The EPAP was applied using a silicon face mask with a one-way valve (Seal Flex
Multi-Strap, Respironics, Ireland, USA) and a spring loaded PEEP valve (Vital Signs
Inc., Totoma, New Jersey, USA) set to 10 cmH2O33. Barbalho-Moulim MC, Miguel GPS, Forti EMP, Costa D. Comparação entre
inspirometria de incentivo e pressão positiva expiratória na função pulmonar após
cirurgia bariátrica. Fisioter Pesqui. 2009;16(2):166-72. http://dx.doi.
org/10.1590/S1809-29502009000200013.
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, which was positioned and fixed by the physical therapist on
the face of the subject to prevent air leakage. The subjects were instructed to
perform six series of 15 breaths, with average-amplitude nasal inspiration and
expiration against the resistance provided by the PEEP valve3232. Borghi-Silva A, Mendes RG, Costa FS, Di Lorenzo VAP, Oliveira CR,
Luzzi S. The influences of positive end expiratory pressure (PEEP) associated with
physiotherapy intervention in phase I cardiac rehabilitation. Clinics (Sao Paulo).
2005;60(6):465-72. http://dx.doi.org/10.1590/S180759322005000600007. PMid:16358136.
https://doi.org/10.1590/S180759322005000...
, emphasizing diaphragmatic breathing. The volunteers rested
for 1-2 minutes between each series, and each session lasted approximately 20
minutes.
The IPPB was applied using a Müller Reanimator device (Engesp(r),
Curitiba, Paraná, Brazil) with an endotracheal pressure of 20-30 cmH2O
corresponding to 2-3 kgf/cm22. Koenig SM. Pulmonary complications of obesity. Am J Med Sci.
2001;321(4):249-79. http://dx.doi.org/10.1097/00000441-200104000-00006.
PMid:11307867.
https://doi.org/10.1097/00000441-2001040...
in the oxygen
pressure regulator valve, and physiological saline was used as the diluent in the
micronebulizer2121. Müller AP. Reanimador de Müller como recurso fisioterapêutico.
Fisioter Mov. 1999;XIII(1):9-16.
,
3333. Müller AP, Olandoski M, Macedo R, Costantini C, Guarita-Souza LC.
Estudo comparativo entre a pressão positiva intermitente (Reanimador de Müller) e
contínua no pós-operatório de cirurgia de revascularização do miocárdio. Arq Bras
Cardiol. 2006;86(3):232-9. http://dx.doi.org/10.1590/S0066-782X2006000300012.
PMid:16612452.
https://doi.org/10.1590/S0066-782X200600...
. The subjects were instructed to inspire
into the device nozzle on the command of the physical therapist simultaneously with
the triggering of the equipment, to sustain the inspiration for 1-2 seconds, and then
to breathe freely. Six series of 15 respiratory cycles were performed during each
session, with 1-2 minutes of rest between each series, with each session lasting
approximately 30 minutes.
The noninvasive application of BIPAP was performed using the VPAP(tm) III ST-A device
(Resmed(r), San Diego, California, USA) connected to a simple facemask
with an inflatable edge by a corrugated trachea and attached to the face of the
subject by a rubber retainer. The EPAP was set to 8 cmH2O, and the
inspiratory positive airway pressure (IPAP) was initially set to 12
cmH2O3434. The Acute Respiratory Distress Syndrome Network. Ventilation with
lower tidal volumes as compared with traditional tidal volumes for acute lung injury
and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8.
http://dx.doi.org/10.1056/ NEJM200005043421801. PMid:10793162.
https://doi.org/10.1056/NEJM200005043421...
and readjusted to
maintain a respiratory rate between 12 and 20 breaths per minute with a TV of
approximately 8 to 10 mL/kg of ideal weight, calculated by the formula 45.5 + 0.91
(height - 152.4)3535. Smith MCL, Ellis ER. Is retained mucus a risk factor for the
development of postoperative atelectasis and pneumonia? -Implications for the
physiotherapist. Physiother Theory Pract. 2000;16(2):69-80. http://dx.doi.
org/10.1080/095939800407268.
https://doi.org/10.1080/095939800407268...
. During the 30 minutes of
application, the subjects were instructed to perform nasal inspiration and oral
expiration.
Throughout the application of the techniques, the subjects remained in the 45º Fowler position, and the investigator remained beside them and monitoring vital signs and respiratory comfort.
Statistical analysis
The statistical analysis of data was performed using the software R version 3.0.1, and the normality of data distribution was verified using the Shapiro-Wilk test.
For the intragroup analysis of spirometric variables and preoperative and postoperative thoracic mobility, Student's t-test for paired samples or the Wilcoxon test was performed. For intergroup comparison, the values of the differences between the pre-and postoperative period were analyzed by ANOVA or Kruskal-Wallis tests.
A significance level of 5% was adopted for all analyses.
Results
Table 1 shows the results of age, anthropometric characteristics and comorbidities of the study subjects allocated to the groups according to the proposed treatment.
There was no difference among groups for the variables age, weight, height, BMI, presence of SAH or presence of diabetes mellitus.
Table 2 shows the spirometric variables of the SVC maneuver of each group for the evaluations before and after surgery in absolute values and as percentages of predicted SVC and ERV values. A significant decrease was observed for all variables in the postoperative period compared to the preoperative period. Table 1 also shows decreases between the pre- and postoperative values in percentages, and when compared with each other, these values were not significantly different.
Table 3 shows the values of thoracic mobility measures at the axillary and xiphoid levels for the groups pre- and post-surgery. The intragroup analysis showed a significant decrease in the axillary and xiphoid mobility for the EPAP and IPPB groups postoperatively; for the BIPAP group, no significant differences were found. When comparing the differences of pre- and postoperative thoracic mobility values, there was no difference between the levels evaluated, regardless of the treatment received.
Discussion
The main results of this study showed a significant decrease in spirometric variables during the postoperative period, regardless of the technique used, and preservation of thoracic mobility only in volunteers from the BIPAP group.
The decreased pulmonary function after surgical procedures can be explained by factors
inherent to the procedure itself, such as the use of anesthetics and analgesics, the
loss of integrity of the abdominal muscles and the consequent decrease in muscle
contraction force and diaphragmatic dysfunction, as well as by factors that interfere in
performing spirometric maneuvers, such as pain and fear of deep inspiration66. Lorentz MN, Albergaria VF, Lima FAZ. Anestesia para obesidade
mórbida. Rev Bras Anestesiol. 2007;57(2):199-213.
http://dx.doi.org/10.1590/S0034-70942007000200010. PMid:19466355
https://doi.org/10.1590/S0034-7094200700...
,
3636. Enzi G, Baggio B, Vianello A. Respiratory disturbances in visceral
obesity. Int J Obes. 1990;14(Suppl 2):26. . In this study, there was concern about
assessing pain and requesting the administration of analgesics according to medical
prescription before the postoperative evaluations, when necessary, to prevent the
results from being affected by this factor. However, we suggest that the effects of the
surgical procedure, associated with obesity, were important contributors to the
significant decrease in spirometry and thoracic mobility values in the three groups.
The excess fat stored in the abdominal cavity exerts a direct mechanical effect on the
ribcage and on the diaphragm, restricting chest expansion, with a consequent decrease in
lung volumes3737. Pelosi P, Croci M, Ravagnan I, Tredici S, Pedoto A, Lissoni A, et
al. The effects of body mass on lung volumes, respiratory mechanics, and gas exchange
during general anesthesia. Anesth Analg. 1998;87(3):654-60. PMid:9728848.
38. Gibson GJ. Obesity, respiratory function and breathlessness. Thorax.
2000;55(Suppl 1):S41-4. http://dx.doi.org/10.1136/ thorax.55.suppl_1.S41.
PMid:10943638.
https://doi.org/10.1136/thorax.55.suppl_...
-
3939. Eichenberger A, Proietti S, Wicky S, Frascarolo P, Suter M, Spahn
DR, et al. Morbid obesity and postoperative pulmonary atelectasis: an underestimated
problem. Anesth Analg. 2002;95(6):1788-92. http://dx.doi.
org/10.1097/00000539-200212000-00060. PMid:12456460.
https://doi.org/10.1097/00000539-2002120...
. This chest wall restriction is greater when
the obese patient is in the supine position, such as during surgery or during the
hospitalization period, causing major muscle overload for ventilation and resulting in
dysfunction of the respiratory muscles4040. Wadström C, Müller-Suur R, Backman L. Influence of excessive weight
loss on respiratory function. A study of obese patients following gastroplasty. Eur J
Surg. 1991;157(5):341-6. PMid:1678648.
,
4141. Ford GT, Rosenal TW, Clergue F, Whitelaw WA. Respiratory physiology
in upper abdominal surgery. Clin Chest Med. 1993;14(2):237-52. PMid:8519170. .
The decreased chest wall compliance due to increased abdominal pressure, administration
of anesthetics and postoperative pain may cause a prolonged reduction in lung volumes
and capacities. The BIPAP therapy is believed to reverse these phenomena through the
combined positive PEEP effects and inspiratory support pressure, allowing the
recruitment of collapsed alveoli zones, increasing pulmonary ventilation and improving
gas exchange, in addition to increasing chest expansion99. Vassilakopoulos T, Mastora Z, Katsaounou P, Doukas G, Klimopoulos S,
Roussos C, et al. Contribution of pain to inspiratory muscle dysfunction after upper
abdominal surgery: A randomized controlled trial. Am J Respir Crit Care Med.
2000;161(4 Pt 1):1372-5. http://dx.doi. org/10.1164/ajrccm.161.4.9907082.
PMid:10764336.
https://doi.org/10.1164/ajrccm.161.4.990...
,
2323. Joris JL, Sottiaux TM, Chiche JD, Desaive CJ, Lamy ML. Effect of
bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative
pulmonary restrictive syndrome in obese patients undergoing gastroplasty. Chest.
1997;111(3):665-70. http://dx.doi.org/10.1378/ chest.111.3.665. PMid:9118706.
https://doi.org/10.1378/chest.111.3.665...
,
4242. Franco AM, Torres FC, Simon IS, Morales D, Rodrigues AJ. Avaliação
da ventilação não-invasiva com dois níveis de pressão positiva nas vias aéreas após
cirurgia cardíaca. Rev Bras Cir Cardiovasc. 2011;26(4):582-90. http://dx.doi.
org/10.5935/1678-9741.20110048. PMid:22358273.
https://doi.org/10.5935/1678-9741.201100...
,
4343. Forgiarini LA Jr, Carvalho AT, Ferreira TS, Monteiro MB, Dal Bosco
A, Gonçalves MP, et al. Atendimento fisioterapêutico no pós-operatório imediato de
pacientes submetidos à cirurgia abdominal. J Bras Pneumol. 2009;35(5):455-9.
PMid:19547854. . However, in this study, BIPAP was not able to
restore lung function postoperatively, and its effectiveness was only observed in the
restoration of the thoracic mobility when compared to the other positive the therapy
exerted a dose and time dependent pressure techniques used. effect, demonstrating better
results when higher
Pessoa et al.1818. Pessoa KC, Araújo GF, Pinheiro AN, Ramos MR, Maia SC. Noninvasive
ventilation in the immediate postoperative of gastrojejunal derivation with Roux-en-Y
gastric bypass. Rev Bras Fisioter. 2010;14(4):290-5. http://dx.doi.
org/10.1590/S1413-35552010005000023. PMid:20949229
https://doi.org/10.1590/S1413-3555201000...
used the BIPAP technique in the
pressure levels were used for prolonged times. immediate postoperative period of
bariatric surgery, Considering this finding, we suggest that more still in
post-anesthetic recovery, and observed that significant results were not found in this
study because the technique was applied for short periods, in 30-minute sessions.
The absence of significant positive effects when using the positive pressure techniques in this study can also be explained by the time that the techniques were applied, as they were only begun approximately four hours after the end of surgery. Forgiarini Junior et al.43 43. Forgiarini LA Jr, Carvalho AT, Ferreira TS, Monteiro MB, Dal Bosco A, Gonçalves MP, et al. Atendimento fisioterapêutico no pós-operatório imediato de pacientes submetidos à cirurgia abdominal. J Bras Pneumol. 2009;35(5):455-9. PMid:19547854. demonstrated that physical therapy, when initiated in the post-anesthetic recovery room, might be beneficial for patients who underwent abdominal surgery because the pulmonary function values in patients who received physical therapy earlier had lower variation in postoperative spirometry values compared to the preoperative values than the group that started physical therapy on the ward.
According to the literature, general anesthesia may worsen hypoventilation during the
early hours of postoperative recovery due to increased alveolar instability during this
period, and the early application of positive pressure might be able to improve alveolar
ventilation in areas that might have collapsed during the surgical procedure4444. Huerta S, DeShields S, Shpiner R, Li Z, Liu C, Sawicki M, et al.
Safety and efficacy of postoperative continuous positive airway pressure to prevent
pulmonary complications after Roux-en-Y gastric bypass. J Gastrointest Surg.
2002;6(3):354-8. http://dx.doi.org/10.1016/S1091255X(01)00048-8. PMid:12022987.
https://doi.org/10.1016/S1091255X(01)000...
45. Moore CE, Forrest M, Ammori B. Anaesthesia for obesity Surgery.
Anaesth Intensive Care Med. 2011;12(7):280-2.
http://dx.doi.org/10.1016/j.mpaic.2011.04.015.
https://doi.org/10.1016/j.mpaic.2011.04....
46. Schumann R. Anaesthesia for bariatric surgery. Best Pract Res Clin
Anaesthesiol. 2011;25(1):83-93. http://dx.doi. org/10.1016/j.bpa.2010.12.006.
PMid:21516916.
https://doi.org/10.1016/j.bpa.2010.12.00...
-
4747. Paisani DM, Chiavegato LD, Faresin SM. Volumes, capacidades
pulmonares e força muscular respiratória no pós-operatório de gastroplastia. J Bras
Pneumol. 2005;31(2):125-32. http://dx.doi.org/10.1590/ S1806-37132005000200007.
https://doi.org/10.1590/S1806-3713200500...
. In the post-anesthesia recovery room, the
patient's tolerance was considered to be facilitated by the residual sedative effect of
anesthetics and opioids administered for analgesia2323. Joris JL, Sottiaux TM, Chiche JD, Desaive CJ, Lamy ML. Effect of
bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative
pulmonary restrictive syndrome in obese patients undergoing gastroplasty. Chest.
1997;111(3):665-70. http://dx.doi.org/10.1378/ chest.111.3.665. PMid:9118706.
https://doi.org/10.1378/chest.111.3.665...
, allowing the techniques to be applied over an extended period of time,
which was not performed in this study because the subjects were already in the hospital
room.
Another important factor to be considered in this study as having a likely effect on the
results, especially regarding lung function, was the time of the postoperative
reassessment. The volunteers were reassessed approximately 36 hours after surgery, and
this time might not have been sufficient for restoring lung volumes and capacities
regardless of the technique applied because until that time, the diaphragmatic function
was not completely restored. In the study by Paisani et al.4747. Paisani DM, Chiavegato LD, Faresin SM. Volumes, capacidades
pulmonares e força muscular respiratória no pós-operatório de gastroplastia. J Bras
Pneumol. 2005;31(2):125-32. http://dx.doi.org/10.1590/ S1806-37132005000200007.
https://doi.org/10.1590/S1806-3713200500...
, which evaluated the pattern of lung volumes and capacities of
patients in the first postoperative period after gastroplasty, decreases of 30 to 50%
were observed in the values of the variables compared to their pre-operative values, and
on the fifth postoperative day, the VC had not yet returned to its initial values. In
the present study, the lung volumes and capacities, also reassessed on the first
postoperative day, decreased by 17 to 46%, and the variables did not recover before
hospital discharge.
In a study by Barbalho-Moulim et al.33. Barbalho-Moulim MC, Miguel GPS, Forti EMP, Costa D. Comparação entre
inspirometria de incentivo e pressão positiva expiratória na função pulmonar após
cirurgia bariátrica. Fisioter Pesqui. 2009;16(2):166-72. http://dx.doi.
org/10.1590/S1809-29502009000200013.
https://doi.org/10.1590/S1809-2950200900...
, EPAP was
unable to prevent the reduction in thoracic mobility at the axillary and xiphoid levels
and of TV and IRV measures, as also occurred in the present study, possibly because EPAP
is a technique that does not stimulate inspiratory "sighs" but instead is associated
with low lung volumes and reduced expiratory flow.
According to Müller et al.3333. Müller AP, Olandoski M, Macedo R, Costantini C, Guarita-Souza LC.
Estudo comparativo entre a pressão positiva intermitente (Reanimador de Müller) e
contínua no pós-operatório de cirurgia de revascularização do miocárdio. Arq Bras
Cardiol. 2006;86(3):232-9. http://dx.doi.org/10.1590/S0066-782X2006000300012.
PMid:16612452.
https://doi.org/10.1590/S0066-782X200600...
, the IPPB technique
allows synchronism between the operator and the patient, respecting the respiratory
cycle, promoting better adaptation to the device and preventing respiratory distress,
and it was thus considered an effective technique for TV gain and hence for lung
re-expansion. However, these beneficial effects were not observed in the present study.
We suggest that techniques with positive pressure have similar effects regarding the restoration of lung volumes and capacities and chest expansion during the postoperative period of bariatric surgery, regardless of being applied during inspiration, expiration or both, and are not effective when applied according to the protocol established for this study, indicating that during the early postoperative days, lung function remains impaired by the obesity effects associated with abdominal surgery effects.
All subjects underwent the same surgical technique by the same surgical team with similar surgery time and anesthesia duration, and during anesthesia, they remained on mechanical ventilation with ventilation parameters standardized by the medical team responsible, which were therefore not considered factors affecting the assessments in this study.
Despite the small effect of positive pressure on pulmonary function and chest mobility of the subjects studied, it is important to note that the techniques applied did not cause any adverse effect or postoperative complications, such as fistula, abdominal distention or dehiscence of the surgical anastomosis. Thus, the present study considered the application of positive pressure during the postoperative period of bariatric surgery to have been safe.
The short hospital stay of subjects who underwent elective bariatric surgery, who were discharged early in the second postoperative day, was considered a limitation of this study because it precluded reassessment at a later time.
Conclusion
The application of bilevel positive airway pressure within the protocol established in this study seems not to be effective in restoring lung volumes and capacities during the postoperative period of bariatric surgery.
Better thoracic mobility results were obtained with the application of bilevel positive pressure than when positive inspiratory or expiratory pressure was applied separately, but this technique was not statistically more effective than the other techniques.
Acknowledgements
The Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), São Paulo, Brazil, process no. 2013/06334-8 and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES/PROSUP), Brasília, Brazil.
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Publication Dates
-
Publication in this collection
09 Jan 2015 -
Date of issue
Nov-Dec 2014
History
-
Received
02 Feb 2014 -
Reviewed
22 Apr 2014 -
Accepted
18 June 2014