Heart, Lung and Circulation (2020) 29, 1180–1186 ORIGINAL ARTICLE

1443-9506/19/$36.00
https://doi.org/10.1016/j.hlc.2019.09.009

Effectiveness of Incentive Spirometry on

Inspiratory Muscle Strength After
Coronary Artery Bypass Graft Surgery
Siriluck Manapunsopee, MD a, Thanitta Thanakiatpinyo, MD a,
Wanchai Wongkornrat, MD b, Benjamas Chuaychoo, MD, PhD c,
Wilawan Thirapatarapong, MD a,*
a
Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
b
Cardiothoracic Division, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
c
Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok,
Thailand

Received 10 March 2018; received in revised form 1 May 2019; accepted 5 September 2019; online published-ahead-of-print 24 October 2019

Background Although the use of incentive spirometry with a deep breathing exercise (DBE) is widely used in clinical
practice in patients who have undergone coronary artery bypass graft (CABG) surgery, the effect of this
combination therapy has not been conclusively elucidated. The aim of this study was to investigate the
effect of postoperative combined incentive spirometry and DBE versus DBE alone on inspiratory muscle
strength following CABG.
Method This randomised clinical trial was conducted in patients scheduled to undergo CABG surgery at Siriraj
Hospital, Bangkok Thailand. The study group received incentive spirometry and DBE, and the control
group received DBE only. Maximal inspiratory pressure (MIP) before surgery and at day 4 after surgery
was assessed by a respiratory pressure meter. Secondary outcomes, including postoperative pulmonary
complication and duration of postoperative hospitalisation, were obtained from the medical records.
Results Ninety (90) patients were included, with 47 and 43 patients assigned to the study and control groups,
respectively. In both groups, there was a significant reduction in MIP from preoperative baseline to
postoperative day 4; however, the MIP in the incentive spirometry group had a significantly smaller
reduction in MIP compared with the control group (33.0623.2% vs 47.2620.1%, respectively; p=0.006, 95%
confidence interval, 3.9-23.3). There was no difference between groups regarding secondary outcomes.
Conclusions Patients in the study group had significantly better recovery of inspiratory muscle strength on day 4 post-
CABG than patients in the control group. There was no significant difference between groups for either
postoperative pulmonary complications or length of hospital stay.
Keywords Incentive spirometry  Inspiratory muscle strength  Maximal inspiratory pressure  Coronary artery
bypass graft surgery

Introduction bypassing obstructed coronary arteries. Although surgical

techniques, anaesthesia techniques, and postoperative care
Coronary artery bypass graft (CABG) surgery is a surgical have improved tremendously [1], the rate of postoperative
procedure to restore normal blood flow to the heart by pulmonary complications (PPCs), including atelectasis,

*Corresponding author at: Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok
10700, Thailand., Emails: jeab_wi44@yahoo.com; wilawan.thi@mahidol.ac.th
Ó 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
Published by Elsevier B.V. All rights reserved.
Incentive Spirometry After CABG
pleural effusion, pneumonia, and pneumothorax, after
CABG surgery has not improved as much and remains a
challenge [2,3]. Deteriorated respiratory muscle condition is
one of the important factors in PPCs [4]. The maximal
inspiratory pressure (MIP) and maximal expiratory pressure
(MEP) values, both of which indicate respiratory muscle
strength, decreased significantly after CABG surgery [5], and
resulted in an increased mortality rate after surgery and
increased duration of hospitalisation [1]. Inspiratory muscle
strength was also found to be a determinant of functional
capacity after CABG surgery [6].
Chest physical therapy increases inspiratory volume and
improves respiratory muscle function, both of which help to
prevent pulmonary complications in the postoperative
period after CABG surgery [2]. Association between respi-
ratory muscle strength training and reduction in respiratory
complications after CABG surgery has been demonstrated
[3]. Use of incentive spirometry increases respiratory muscle
strength [7,8], expands breathing volume [9,10], and im-
proves oxygen saturation [7]. Importantly, incentive
spirometry helps patients to learn from visual feedback,
which encourages them to practice breathing [11,12]. Incen-
tive spirometry is also affordable and easy to use. As a result
of these many advantages, incentive spirometry is used
worldwide in clinical practice in patients scheduled to un-
dergo CABG. Surprisingly, a Cochrane review of the effec-
tiveness of incentive spirometry after CABG reported no
advantage over conventional postoperative chest physical
therapy for preventing postoperative complications,
improving lung function, or decreasing postoperative hos-
pital stay [13]. However, most of the studies evaluated were
performed in small cohorts and many had methodological
shortcomings [14]. In addition, one study compared respi-
ratory muscle strength between incentive spirometry alone
and incentive spirometry with intermittent positive pressure
[7], and another demonstrated this only in patients with a
high risk for pulmonary complication [8]. Moreover, several
previous studies compared deep breathing exercises (DBEs)
alone with incentive spirometry alone; however, incentive
spirometry combined with DBEs is now widely practised,
which makes previous comparative data incompatible with
current clinical protocols [15].
To our knowledge, and based on our review of the liter-
ature, there are no published studies that have comparatively
investigated the effect of incentive spirometry in combination
with DBE and general physiotherapy on respiratory muscle
strength. Accordingly, the aim of this study was to investi-
gate the effect of postoperative combined incentive spirom-
etry and DBE versus DBE alone on inspiratory muscle
strength following CABG surgery.
Methods
Study Design and Patients
This randomised clinical trial was conducted in patients
scheduled to undergo CABG surgery at the Division of
1181
Cardiothoracic Surgery, Department of Surgery, Siriraj
Hospital, Bangkok Thailand, from April 2016 to November
2016. The protocol for this study was approved by the
Institutional Review Board (approval no. 662/2558 [EC4]),
and complied with the principles set forth in the Decla-
ration of Helsinki and all of its subsequent amendments.
Written informed consent was obtained from all study
participants. The study was registered with the Thai
Clinical Trials Registry (TCTR) (2016090700; www.
clinicaltrials.in.th).
Inclusion criteria
Patients aged 18 years or older who were scheduled for
elective CABG surgery from April to November 2016 were
eligible for inclusion.
Exclusion criteria
Patients meeting one or more of the following criteria were
excluded: (1) haemodynamic instability on the day of
admission; (2) communication problems; (3) inability to
measure respiratory muscle strength for any reason; (4)
having a malformed mouth or palate without correction, or a
weak mouth; (5) history of incentive spirometry use in the
past month; (6) prolonged endotracheal tube for more than
36 hours; (7) complication requiring re-insertion of the
airway after surgery; and/or (8) inability to follow-up or
continue the study program protocol.
Procedure
Surgical and postoperative procedure
All patients received general anaesthesia. CABG was per-
formed via median sternotomy using the saphenous vein
and/or the left internal mammary artery and radial artery
under cold-blood cardioplegia and moderate hypothermia
(28–32 C). In the postoperative period, patients underwent
mechanical ventilation with a positive end-expiratory pres-
sure of 2-5 cmH2O and a tidal volume of 6-10 mL/kg.
Analgesia (intravenous morphine and oral paracetamol) in
the postoperative period was optimised and followed the
standard protocol used at our centre. Patients were extu-
bated after achieving haemodynamic stability, adequate
diuresis, and no active bleeding.
Randomisation, intervention, and follow-up
Patients were stratified by age and sex, as these factors
significantly affect respiratory muscle strength [16]. Patients
were assigned to undergo incentive spirometry and DBE (IS/
study group) or DBE only (control group). A computer-
generated randomisation table was used, and individual al-
locations were placed in sealed envelopes. An external inves-
tigator blinded to the allocation sequence picked consecutive
allocation envelopes for consecutive participants.
Before surgery, all patients were educated about potential
postoperative complications and how to practice postoperative
physical therapy, including DBE, coughing and/or Huff tech-
niques, daily active exercise of upper/lower extremities, and
mobility training. After surgery and extubation, both groups
1182
Assessed for eligibility (n=129)
Enrolment
Randomisation (n=90)
Intervention group (n=47)
Withdrawal (n=9)
- Lost to follow-up (n=4)
- Communication problem due to confusion (n=2)
- Dyspnoea due to heart failure and arrhythmia (n=3)
Analysed (n=47)
Figure 1 Study flowchart.
Abbreviations: MIP, maximal inspiratory pressure; IS, incentive spirometry.
received general physical therapy once daily by physical ther-
apists. Physical therapy consisted of DBE, early mobilisation,
and titrated ambulation. In most cases, the patients were sitting
out of bed and/or standing on the first operative day, standing
and transferring to a chair on the second day, walking a short
distance on the third day, and walking longer distances there-
after. Both groups received the same standard of physical
therapy in the first 4 days after surgery.
All patients had practised DBE from the preoperative
period, and then began DBE therapy on the first day after
extubation. Patients were encouraged to perform DBE 10 times
per waking hour. This was performed by resting one hand on
the chest and the other on the abdomen, inhaling slowly and
deeply, keeping the chest and abdomen expanded for at least 3
seconds, and then slowly exhaling. Patients in the incentive
spirometry group received additional instruction in the use of
flow-type incentive spirometry (Pulmo-gain; Phartrillion Co.
Ltd, Bangkok, Thailand). Patients were encouraged to perform
incentive spirometry 10 times per waking hour in a sitting
S. Manapunsopee et al.
Excluded (n=39)
- Unable to perform MIP measurement (n=11)
- Weakness of facial muscle (n=3)
- Aortic aneurysm (n=3)
- Chest pain (n=5)
- Used IS within the past month (n=14)
- Communication problem (n=7)
- Declined to participate (n=7)
Control group (n=43)
Withdrawal (n=10)
- Lost to follow-up (n=2)
- Communication problem due to confusion (n=2)
- Dyspnoea due to heart failure and arrhythmia (n=6)
Analysed (n=43)
position while holding the device at eye level. Patients were
instructed to perform slow maximal inhalations while holding
the ball at the same level for 3-5 seconds, or as long as possible.
Outcome Measurement
Maximal inspiratory pressure was assessed by an investi-
gator or assessor blinded to study group assignment on
preoperative day and postoperative day 4 using a respiratory
pressure meter (MicroRPM; CareFusion, San Diego, CA,
USA). Patients underwent evaluation in the sitting position.
Three measurements were performed with sustained inspi-
ration for at least 2 seconds, with the best value being
recorded and each of the three values not varying from each
other by more than 20% [17].
Postoperative pulmonary complications, including atelec-
tasis, pleural effusion, pneumonia, and pneumothorax. The
postoperative pulmonary complication was evaluated and
recorded by a blinded independent cardiothoracic surgeon,
Incentive Spirometry After CABG 1183

Table 1 Baseline demographic and clinical patient Table 2 Surgical and anaesthesia data.
characteristics.
Variables Intervention Control
Variable Intervention Control group (n=47) group (n=43)
group (n=47) group (n=43)
Duration of surgery (min) 226.06104.0 258.06103.0
Age (y) 65.0611.0 65.069.0 Type of CABG
Sex On-pump 45 (96) 42 (98)
Male 32 (68) 30 (70) Off-pump 2 (4) 1 (2)
Female 15 (32) 13 (30) Cardiopulmonary bypass 109.0655.0 129.0657.0
BMI (kg/m2) 24.963.4 24.863.6 time (min)
History of smoking 6 (13) 7 (16) Duration of endotracheal 10 (4-96) 14 (4-107)
Comorbidity intubation (h)
Diabetes mellitus 27 (57) 23 (53) Duration of chest drain (h)
Hypertension 43 (91) 39 (91) Pericardial drain 51 (20-123) 51 (35-152)
Dyslipidaemia 36 (77) 25 (58) Intercostal drain 60 (20-123) 57 (35-152)
COPD 0 (0) 1 (2) Maximal pain score each
eGFR (mL/min/1.73m2) 68.8625.9 59.9623.6 postoperative day
Ejection fraction (%) 54.0619.0 48.0616.0 (11-point numeric scale)
NYHA class Day 1 5 (0-10) 5 (3-10)
I 17 (36) 22 (51) Day 2 3 (0-10) 3 (0-10)
II 27 (57) 17 (39) Day 3 0 (0-10) 0 (0-5)
III 3 (6) 4 (9) Day 4 0 (0-10) 0 (0-5)
Affected vessels Dose of IV analgesia 15 (6-43) 15 (0-65)
1 1 (2) 0 (0) (equivalent dose of
2 9 (19) 4 (9) morphine IV) (mg)
3 37 (79) 39 (91)
Data are mean 6 standard deviation, n (%), or median (minimum-maximum).
No statistically significant differences were observed between groups. No statistically significant differences were observed between groups.
Data are mean 6 standard deviation or n (%). Abbreviations: CABG, coronary artery bypass graft; IV, intravenous.
Abbreviations: BMI, body mass index; COPD, chronic obstructive
pulmonary disease; eGFR, estimated glomerular filtration rate; NYHA,
New York Heart Association.

differences in MIP, a minimum of 41 patients were required

using clinical (symptoms or lung findings) plus radiographic
findings.
Length of hospital stay started the day after surgery and
ended the day the patient was discharged to home.
Side effects from breathing exercises, including dyspnoea,
surgical pain, and dehiscence, were assessed from patients.
Comfort score, which was calculated from a numeric rating
scale, was assessed on day 4 after breathing training in both
groups. Each score was defined, as follows: 1 = feeling
comfortable with breathing exercises; 2 = not feeling comfort-
able with breathing exercises but can continue to practice; 3 =
feeling pain, discomfort, and/or uneasy but can continue to
practice; 4 = feeling a lot of pain but can continue to practice;
and, 5 = feeling a lot of pain and unable to continue practice [18].
Frequency of self-practice of breathing exercises per day
was documented by a physiotherapist based on patient-
provided compliance information.
for each group. To compensate for 10% withdrawal for any
reason, eight patients were added for a total study popula-
tion of 90 patients.
Statistical analysis was performed using SPSS Statistics
version 18 (SPSS Inc., Chicago, IL, USA). The Kolmogorov–
Smirnov test was used to test for normal distribution of
data. Descriptive data were presented as number and per-
centage, mean 6 standard deviation, or median (minimum-
maximum). For intention-to-treat analysis, differences in MIP
and continuous variables within and between the groups
were determined using the Student’s t-test. Postoperative
pulmonary complications between groups were analysed
using the chi-square test. Between-group comparisons for
length of hospital stay and comfort score between groups
were performed using the Mann–Whitney U-test. A p value
,0.05 was regarded as being statistically significant.

Sample Size Calculation and Statistical Results

Analysis Patient Baseline Characteristics
Using a probability of type I error of 95%, a probability of During the 7-month recruitment period, 129 patients hospi-
type II error of 20%, and an 80% power to detect 12% talised for non-emergency CABG surgery were screened for
1184
Figure 2 Maximal inspiratory pressure (MIP) before
surgery and at day 4 after coronary artery bypass
grafting (CABG) compared between the incentive
spirometry (IS) and control groups. Reported values
expressed as mean 6 standard deviation. *Significant
difference between preoperative result and the result on
postoperative day 4 in both groups (p,0.05). **Signifi-
cant difference between the IS and control groups on
postoperative day 4 (p,0.05); USignificant difference in
reduction of MIP between the IS and control groups
(p,0.005).
eligibility (Figure 1). Of these, 90 fulfilled the inclusion
criteria and were enrolled. Forty-seven (47) patients and 43
patients were assigned to the incentive spirometry group and
control group, respectively. After surgery, nine patients in
the incentive spirometry group and 10 patients in the control
group could not be actively treated as per protocol; however,
data from all 90 originally included patients were included in
the final analysis (Figure 1).
Patient baseline demographic and clinical characteristics
are summarised in Table 1. There were no significant dif-
ferences between groups regarding age, sex, body mass in-
dex, smoking history, comorbidities, estimated glomerular
filtration rate, left ventricular ejection fraction, New York
Heart Association class, or number of affected vessels.
Similarly, there were no significant differences in surgical or
anaesthesia data between groups (Table 2). Both groups
received similar care according to standard guidelines for
treating postoperative CABG.
Primary Outcome
Maximal inspiratory pressure before surgery and on post-
operative day 4 in both groups is shown in Figure 2 and
Table 3 Preoperative and postoperative day 4 maximal inspiratory pressure (MIP) compared between groups.
Variables
Preoperative MIP (cmH2O)
Postoperative day 4 MIP (cmH2O)
Difference between preoperative and postoperative MIP (%)
Data are mean 6 standard deviation.
Abbreviation: CI, confidence interval.
a
Statistically significant difference in the intervention group (p,0.05).
b
Statistically significant difference in the control group (p,0.05).
S. Manapunsopee et al.
Table 3. There was no significant difference in MIP between
groups before surgery. In both groups, there was a signifi-
cant reduction in MIP from preoperative baseline to post-
operative day 4; however, MIP in the incentive spirometry
group had a significantly smaller reduction in MIP compared
with the control group (33.0623.2% vs. 47.2620.1; p=0.006,
95% confidence interval [CI], 3.9-23.3).
Postoperative Pulmonary Complications
and Length of Hospital Stay
There was no significant difference in postoperative respi-
ratory complications or duration of hospital stay after sur-
gery between groups (Table 4).
Comfort Score and Side Effects
No significant difference was observed between groups for
breathing exercise comfort score. A significantly larger
number of patients reported dyspnoea during the breathing
exercise in the study group than in the control group (p=0.03)
(Table 5). However, there was no significant difference be-
tween groups for either pain or dehiscence.
Compliance With Self-Practice Breathing
Exercise Protocol
Based on day-after-day inquiries and patient records
regarding the frequency of breathing training, 80% of pa-
tients in each group responded to this question. On all four
postoperative days, patients in the incentive spirometry
group performed a greater number of breathing exercises
than patients in the control group. However, the difference
between groups was statistically significant only on post-
operative day 3 (p=0.02) (Table 6).
Discussion
To our knowledge, this is the first randomised controlled
trial to study the effects of combined incentive spirometry
and DBE on respiratory muscle strength after CABG surgery.
The results revealed combination therapy with incentive
spirometry and DBE to improve respiratory muscle strength
than DBE alone.
Morsch et al. [19] found inspiratory muscle strength after
CABG to be statistically significantly lower than before
Intervention group (n=47) Control group (n=43) P-value 95% CI
71.7628.1 74.1626.6 0.68
45.3621.6a 36.5617.6b 0.04
34.1622.1 47.1619.2 0.004 4.2-21.6
Incentive Spirometry After CABG 1185

Table 4 Number of postoperative days and postoperative pulmonary complications compared between groups.

Variables Intervention Control P-value OR (95% CI)

group (n=47) group (n=43)

Number of postoperative days, median (minimum-maximum) 7 (3-14) 7 (4-35) 0.42

Postoperative pulmonary complications 13 (28) 13 (30) 0.79 0.88 (0.35-2.19)
Atelectasis 3 (6) 5 (12) 0.38 0.52 (0.12-2.31)
Pneumonia 1 (2) 0 (0) 0.34 –
Pneumothorax 0 (0) 1 (2) 0.29 –
Pleural effusion 9 (19) 8 (19) 0.95 1.04 (0.36-2.98)

Data are n (%) unless otherwise indicated. A p value ,0.05 indicates statistical significance.
Abbreviations: OR, odds ratio; CI, confidence interval.

surgery. They reported type of surgery, postoperative anal-
gesia, duration of use of cardiopulmonary bypass during
surgery, and postoperative pain to be factors that contribute
to reduction in postoperative inspiratory muscle strength
[16]. We included all of these factors in our analysis, and no
statistically significant difference was found between groups
for any of them.
Renault et al. [15] reported no significant difference in
postoperative respiratory muscle strength when comparing
incentive spirometry with DBE. However, and as previously
mentioned, we found combined therapy with incentive
spirometry and DBE to be more efficacious for improving
respiratory muscle strength than therapy using only DBE.
Romanini et al. [7] suggested increase in the reinforcement of
the inspiratory muscles and recruitment of motor unit via the
benefit of visual feedback to be the mechanisms of incentive
spirometry on recovery of respiratory muscle strength.
In this study, we found respiratory muscle strength in the
combined therapy group to be reduced by 33% on the fourth
day after CABG. Haeffener et al. [20] studied the effect of
using incentive spirometry combined with expiratory posi-
tive airway pressure versus DBE after CABG, and found
inspiratory muscle strength to be reduced by only 15% on
postoperative day 7 [20]. It is therefore possible that the day
of measurement after CABG is another factor that influences
differences in respiratory muscle strength. A previous study
found day-after-day improvement in respiratory muscle
strength after cardiac surgery [15]. Further investigation into
other combinations of respiratory therapeutic devices in this
patient population is warranted.
The present study did not find any differences in length of
hospital stay or pulmonary complications after CABG be-
tween groups. In contrast, Haeffener et al. [20] found PPCs
and length of hospital stay after CABG to be lower in the
group using incentive spirometry combined with expiratory
positive airway pressure than in those who only practised
respiratory exercise.
In this study, we found no difference between groups for
separated surgical lesion or comfort score; however, the
combined therapy group reported significantly more fatigue
during breathing training. Given that the median comfort
score was 2 in the study group and that most patients were
able to continue their breathing training, it is possible that the
fatigue they reported may not be clinically important.
Study Limitations
This study has some mentionable limitations. Firstly, and
given the nature of the therapy, we were not able to blind
both patients and clinicians. As such, this was a single-
blinded study. Secondly, the total number of patients

Table 5 Comfort score and adverse events from self-breathing exercises compared between groups.

Variables Intervention Control P-value OR (95% CI)

group (n=42) group (n=37)

Comfort score (range, 1-5), median (minimum-maximum) 1 (1-3) 1 (1-3) 0.12

n=46 n=39
Total adverse events 16 (35) 10 (26) 0.36 154 (0.60-3.96)
Pain 12 (26) 10 (26) 0.96 1.02 (0.38-2.71)
Dyspnoea 5 (11) 0 (0) 0.03 –
Dehiscence 0 (0) 0 (0) – –

Data are n (%) unless otherwise indicated.

A p value,0.05 indicates statistical significance.
Abbreviations: OR, odds ratio; CI, confidence interval.
1186
Table 6 Compliance with self-breathing exercise
protocol compared between groups (times/day).
Variable Intervention Control P-value
group (n=40)a group (n=33)a
Postoperative day 1 20 (0-70) 10 (0-100) 0.70
Postoperative day 2 40 (0-200) 30 (0-100) 0.15
Postoperative day 3 60 (0-270) 40 (10-100) 0.02
Postoperative day 4 65 (0-250) 50 (20-100) 0.29
Data are median (minimum-maximum). A p-value,0.05 indicates statis-
tical significance.
a
80% of patients in each group responded to this self-breathing compli-
ance-related question.
excluded during the course of the study exceeded the 10%
maximum anticipated withdrawal rate, and this may have
adversely affected our ability to identify significant associa-
tions or differences between groups. Thirdly, our study made
a comparison between two groups and not an in-group
comparison, so that the total number required to show a
clinical difference might be much larger. Lastly, our study
evaluated only flow-type incentive spirometry. Further
study in volume-type incentive spirometry is warranted.
Conclusions
Patients in the combined DBE and incentive spirometry
group had significantly better recovery of inspiratory muscle
strength on day 4 post-CABG than patients in the DBE-only
group. There was no significant difference between groups
for either postoperative pulmonary complications or length
of hospital stay.
Acknowledgments
This study was supported by the Siriraj Research Develop-
ment Fund (Managed by Routine to Research: R2R), the
Faculty of Medicine Siriraj Hospital, Mahidol University,
Bangkok, Thailand (grant no. R2R329/16). Funding in-
stitutions had no role in the design of the study, the collec-
tion and analysis of the data, or the preparation of the
manuscript. In addition, we are grateful to Dr Saowaluk
Hunnangkul for her assistance with the statistical analysis.
Conflict of Interest
There are no conflicts of interest to disclose.
S. Manapunsopee et al.
References
[1] Wynne R, Botti M. Postoperative pulmonary dysfunction in adults after
cardiac surgery with cardiopulmonary bypass: clinical significance and
implications for practice. Am J Crit Care 2004;13:384–93.
[2] Westerdahl E, Lindmark B, Eriksson T, Friberg O, Hedenstierna G,
Tenling A. Deep-breathing exercises reduce atelectasis and improve
pulmonary function after coronary artery bypass surgery. Chest
2005;128:3482–8.
[3] Hulzebos EH, Helders PJ, Favié NJ, De Bie RA, Brutel de la Riviere A,
Van Meeteren NL. Preoperative intensive inspiratory muscle training to
prevent postoperative pulmonary complications in high-risk patients
undergoing CABG surgery. JAMA 2006;296:1851–7.
[4] Ferreira PE, Rodrigues AJ, Évora PR. Effects of an inspiratory muscle
rehabilitation program in the postoperative period of cardiac surgery.
Arq Bras Cardiol 2009;92:261–8.
[5] Barros GF, Santos CS, Granado FB, Costa PT, Límaco RP, Gardenghi G.
Respiratory muscle training in patients submitted to coronary arterial
bypass graft. Rev Bras Cir Cardiovasc 2010;25:483–90.
[6] Stein R, Maia CP, Silveira AD, Chiappa GR, Myers J, Ribeiro JP. Inspi-
ratory muscle strength as a determinant of functional capacity early after
coronary artery bypass graft surgery. Arch Phys Med Rehabil
2009;90:1685–91.
[7] Romanini W, Muller AP, Carvalho KA, Olandoski M, Faria-Neto JR,
Mendes FL, et al. The effects of intermittent positive pressure and
incentive spirometry in the postoperative of myocardial revasculariza-
rion. Arq Bras Cardiol 2007;89:94–9.
[8] Weindler J, Kiefer RT. The efficacy of postoperative incentive spirometry
is influenced by the device-specific imposed work of breathing. Chest
2001;119:1858–64.
[9] Kundra P, Vitheeswaran M, Nagappa M, Sistla S. Effect of preoperative and
postoperative incentive spirometry on lung functions after laparoscopic
cholecystectomy. Surg Laparosc Endosc Percutan Tech 2010;20:170–2.
[10] Paisani DM, Lunardi AC, da Silva CC, Porras DC, Tanaka C,
Carvalho CR. Volume rather than flow incentive spirometry is effective in
improving chest wall expansion and abdominal displacement using op-
toelectronic plethysmography. Respir Care 2013;58:1360–6.
[11] Bartlett RH, Brennan ML, Gazzaniga AB, Hanson EL. Studies on the
pathogenesis and prevention of postoperative pulmonary complications.
Surg Gynecol Obstet 1973;137:925–33.
[12] Westerdahl E, Lindmark B, Eriksson T, Hedenstierna G, Tenling A. The
immediate effects of deep breathing exercises on atelectasis and
oxygenation after cardiac surgery. Scand Cardiovasc J 2003;37:363–7.
[13] Freitas ER, Soares BG, Cardoso JR, Atallah ÁN. Incentive spirometry for
preventing pulmonary complications after coronary artery bypass graft.
Cochrane Database Syst Rev 2012:CD004466.
[14] Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. Physio-
therapy after coronary artery surgery: are breathing exercises necessary?
Thorax 1989;44:634–9.
[15] Renault JA, Costa-Val R, Rossetti MB. Respiratory physiotherapy in the
pulmonary dysfunction after cardiac surgery. Rev Bras Cir Cardiovasc
2008;23:562–9.
[16] Chen HI, Kuo CS. Relationship between respiratory muscle function and
age, sex, and other factors. J Appl Physiol 1989;66:943–8.
[17] Pessoa IMBS, Coelho CM, Mendes LPS, Montemezzo D, Pereira DAG,
Parreira VF. Comparison of three protocols for measuring the maximal
respiratory pressures. Fisioter Mov 2015;28:31–9.
[18] Clinkscale D, Spihlman K, Watts P, Rosenbluth D, Kollef MH.
A randomized trial of conventional chest physical therapy versus high
frequency chest wall compressions in intubated and non-intubated
adults. Respir Care 2012;57:221–8.
[19] Morsch KT, Leguisamo CP, Camargo MD, Coronel CC, Mattos W,
Ortiz LD, Lima GG. Ventilatory profile of patients undergoing CABG
surgery. Rev Bras Cir Cardiovasc 2009;24:180–7.
[20] Haeffener MP, Ferreira GM, Barreto SS, Arena R, DallÁgo P. Incentive
spirometry with expiratory positive airway pressure reduces pulmonary
complications, improves pulmonary function and 6-minute walk distance
in patients undergoing coronary artery bypass graft surgery. Am Heart J
2008;156:900.e1–8.