Research Proposal

Effects of Deep Breathing Exercises and Splinted Coughing Exercises to Prevent

Respiratory Complication after Abdominal Surgery

By Dennis Rantung

I. Introduction
Breathing is the most vital function for maintenance of life. Slow and deep
breathing is an integral part of pranayama and it reduces dead space ventilation
and renews air through out the lungs.
Physiotherapy treatment for patients after open abdominal surgery
consists of a variety of interventions intended to improve cardiopulmonary and
or physical function ad reduce the incidence of postoperative pulmonary
complications. These interventions may include lung expansion, exercises,
secretion clearance techniques, limb exercises, progressive mobilization
programs and other techniques.
Respiratory complication such as pneumonia, atelectasis and respiratory
failure are the leading cause of morbidity and mortality in the immediate
postoperative period. ( Monahan et al, 2007), moreover, these complications
may cause prolonged hospital stay and increase in hospital cost. However, such
complications can be prevented. Lung compliance is the ease with which the lung
volume is changed. The lungs have a continual tendency to collapse because of
the elastic connective tissue and the surface tension of the fluid lining the alveoli.
To reduce surface tension and to increase elasticity the alveolar membrane
secrets a lipoprotein called surfactant, which reduces the amount of pressure
needed to fill the alveoli during inspiration and helps to maintain alveolar
patency during expiration. (Osborn, Wraa, et al,2010)
The incidence of postoperative pulmonary complication after abdominal
surgery in the literatures varies from 5% to 30%. In abdominal surgery, patients
developed restricted pattern of breathing postoperatively with a decrease in
peak expiratory flow rate and functional residual capacity (FRC). This decrease
in lung volume is associated with hypoxemia, broncho-pulmonary infection,
pneumonia, airway obstruction and eventually progress to postoperative
respiratory failure. Decreased mucociliary clearance, diaphragm dysfunction,
shallow and monotonous breathing also develop postoperatively in upper
abdominal surgery patients and cause pulmonary complications. (Mayer, 2012).
According to 2009 statistic in the US, pulmonary complications
represented one of the most common cause of death (38.2%) or 5,270 cases,
cardiac failure 17.6%, respiratory failure 11.8% or 1525 among postoperative
complication cases. A study was done in South Korea about the risk of
postoperative complication cases and found out that pulmonary complication
involved the cardiac (20%) and pulmonary (14%) as the common complication.
According to the study done by Bangue, et al, in the Philippines Heart Center, the
rate of post-operative pulmonary complication is 73% and 87 cases is with
atelectasis.
Respiratory therapy can reduce the incidence of post-operative
pulmonary complications from 60-80% to 19-30% physiologically (White, 2005)
and the best means to encourage normal lung expansion is spontaneous deep
breathing and coughing exercises in which they are important adjuncts to post-
operative care. Regular performance of deep breathing and coughing exercises
can decrease the incidence of pulmonary complications from about 30% to 10%
(Harnett, 2012). Bay (2010) further explained that chest physiotherapy is
frequently used in the prevention and treatment of postoperative pulmonary
complications after major abdominal surgery. Chest physiotherapy techniques
include deep breathing exercises and splinted coughing.

II. Research Question

In post abdominal surgery patients, can deep breathing exercises and splinted
coughing exercises increase the peak expiratory flow rate?

III. Objective
The study primarily aims to determine the effect of deep breathing exercises and
splinted coughing exercises on the peak expiratory flow rate.

IV. Methodology
To meet the research objectives, a quasi-experimental interrupted time-series
with control group research design will be utilized in this study. The
independent study were grouped and classified as deep breathing and splinted
coughing exercises, while the dependent variables were peak expiratory flow
rate.
The following illustrates the design used in this study:

Experimental Group O1 X1 O2 X2 O3 X3 O4
Control Group O5 O6 O7 O8

O1 Pre measurement of peak expiratory flow rate and vital signs of post
abdominal surgery patients on the experimental group 23 hours after the
surgery.
X1 Implementation of structured deep breathing and splinted coughing
exercise immediately after the pre-measurement
O2 Post measurement of peak expiratory flow rate and vital signs 24 hours
after the surgery
X2 Implementation of structured deep breathing and splinted coughing
exercise 47 hours after the surgery
O3 Post measurement of peak expiratory flow rate and vital signs 48 hours
after the surgery
X3 Implementation of structured deep breathing and splinted coughing
exercise 71 hours after the surgery
O4 Post measurement of peak expiratory flow rate and vital signs 72 hours
after the surgery
O5 Pre measurement of peak expiratory flow rate and vital signs on the
control group 23 hours after the surgery
O6 Measurement of peak expiratory flow rate and vital signs of post
abdominal surgery patients on the control group 24 hours after the
surgery.
O7 Measurement of peak expiratory flow rate and vital signs on the control
group 48 hours after the surgery.
O8 Measurement of peak expiratory flow rate and vital signs on the control
group 72 hours after the surgery.

Population and Sampling Techniques:

The participants were recruited from Adventist Medical Center Manila
(AMCM). Inclusion criteria: Post abdominal surgery patients who were confined
in hospital, 19 to 60 years old, and has provided a consent to participate in the
study. Exclusion criteria: Patients who had other surgical intervention/s aside
from abdominal surgery, those with history of cardio and or pulmonary
problems, and those who did not sign consent.
The first 20 participants were comprised as the control group who
received no intervention, and the next 20 participants were comprised as
experimental group who received structured deep breathing and splinted
coughing exercise done by researcher. This method was used to prevent a cross-
over effect from experimental group to the control group.
According to Sevilla et al, for experimental research, 30 per group as
minimum acceptable size of population, although 15 sub-subjects are acceptable.
Intervention:
- Experimental Group:
o Deep Breathing exercises : Patient is to breathe in slowly and
deeply through the nose, hold breath for 3 seconds, then tell the
patient to slowly let all air out through the mouth. Procedure is to
be done 10 times.
o Splinted Coughing exercises: Patient is to inhale slowly through
the mouth while breathing deeply, then patient is to forcefully
exhale quickly. Exercise is to be repeated 5 times with 30 seconds
interval between the 5 exercises
- Control Group : Regular deep breathing exercises

Data Collection
Data Collection include age, sex, weight, smoking history, opium use, alcohol
consumption, comorbidities, procedure, anesthesia

Criteria for a clinical significant pulmonary complication :

- Auscultation changes (decreased breath sounds, crackles, wheezes) that
were additional prior to surgery.
- Temperature over 37.8
- Increase in amount and/or changed color of sputum produced, compared
to what the patient reports is usual for them
- Chest x-ray changes consistent with collapse, consolidation, or atelectasis.