Active Cycle Breathing Technique on Pulmonary Complications After Coronary Artery Bypass Graft

The most widely recognized postoperative complexities are watched and overseen after abdominal or cardiothoracic surgery are pulmonary complications and it is continue to contribute to patient morbidity and mortality. Hence, this study was conducted with the aim to determine the effectiveness of active cycle of breathing technique on pulmonary complications after coronary artery bypass surgery. Pre-experimental research design was adopted to conduct the study with 20 samples who met the inclusion criteria. Demographic variables were collected by using structured questionnaire and assessed the physiological parameters such as oxygen saturation, respiratory rate, and heart rate, systolic and diastolic blood pressure. Followed by active cycle of breathing technique was administered to the participants twice a day for 3 days from the irst post-operative day onwards. Pre and post assessment was done each day before and after the intervention and post-test value was taken for analysis. Post-operative complications were assessed at the end of 3 day of intervention by using the checklist contains the pulmonary complications due to surgery. Data were analyzed using SPSS statistical package. There was a signi icant improvement was observed in oxygen saturation, respiratory and heart rate at the level of p<0.05 and the percentage of complications also very minimal. The indings of the study concluded that active cycle breathing technique is effective in pulmonary function thereby prevent the pulmonary complications after coronary artery bypass graft.


INTRODUCTION
Coronary artery bypass grafting (CABG) is a technique of an area of a vein is joined from the aorta to the coronary artery to bypass the congested part of the coronary artery to alleviate the coronary perfusion to the myocardium of the heart in the event of coronary artery disease such as myocardial infarction. It is as yet the most ordinarily executed cardiac surgery strategy around the world, speaking to yearly volumes of roughly 200,000 segregated cases (Weiss and Elixhauser, 2001) in the US and a normal occurrence pace of 62 for each 100,000 occupants in western European nations ( OECD, 2009;Head et al., 2017). The number of bypass procedures is expanding in India and it is around 60,000 coronary bypass procedures are made every year (Kaul and Bhatia, 2010).
The most widely recognized postoperative complexities are watched and overseen after abdominal or cardiothoracic surgery are pulmonary complications (Brooks-Brunn, 1995) . It continues to con-tribute to patient morbidity and mortality, length of stay, and generally utilization of assets regardless of various advances in preoperative, intraoperative, and postoperative consideration. The most as often as possible discovered hazard factors for pulmonary hazards are propelled age, overabundance weight, history of cigarette smoking, diabetes mellitus, irregular pneumonic capacity, and chronic obstructive pulmonary disease (Gaynes et al., 1991;Garibaldi et al., 1981). The aetiology of pulmonary hazards after cardiac surgery are open heart multifactorial association between anesthesia, (Windsor and Hill, 1988;Nogare, 1994;Renault et al., 2008) surgical trauma, cardiopulmonary bypass, cardiac arrest, time of medical procedure, duration of the mechanical ventilation and pain, causing decreased functional residual capacity, increased intrapulmonary shunt and enlargement of alveolararterial oxygen (Luchesa et al., 2009;Westerdahl et al., 2005). The most common postoperative respiratory complications are atelectasis and hypoxemia (Guizilini et al., 2005;Feltrim et al., 2007). However, different hazards such as dry or productive cough, dyspnea, bronchospasm, hypercapnia, pleural effusion, pneumonia, pneumothorax, re-intubation and insuf iciency ventilation are also observed (Moreno et al., 2011). Also, the duration of hospital stay for this type of interventions usually leads to distress, stress, depression, eagerness, weariness, intensi ication of pain and uneasiness both in the pre and postoperative period, which can in luence oxygen transport preferring the improvement of postoperative complications (Stiller and Munday, 1992).
The best mediations, for example, breathing and coughing exercises, early ambulating, and pneumonic clearing methods are frequently used to forestall aspiratory inconveniences after coronary artery bypass graft (CABG) surgery (Mckoy et al., 2012). Amongst active cycle of breathing technique (ACBT) is a functioning breathing procedure might be actualized by the patient to extricate and clear discharges from the lungs (Thomson et al., 1994), improve ventilation in the lungs and to improve the adequacy of a cough (Guy and Thomas, 2018;Sumansheraz and Ahmedsiddiqi, 2015). It can be perform freely by quiet with about applying manual strategy. ACBT is very compelling method to improve oxygen saturation, control respiratory rate, and chest clearance after major surgeries. In 2015 an investigation was led to assess the impacts of ACBTs on chest extension, blood vessel blood gases, oxygen saturation, blood pressure, respiratory rate and other vitals in chronic obstructive pulmonary disease patients during the irst phase of cardiac recovery after CABG medical procedure and presumed that ACBT are a lot of viable than routine physiotherapy convention in patients who have gone under coronary artery bypass grafting (Pryor and Webber, 1994). Considering the potential improvement the investigators are interested in studying the effectiveness of active cycle of breathing technique with the hypothesis of signi icant reduction in pulmonary complications after the implementation of ACBT among patients who had undergone coronary artery bypass surgery.

MATERIALS AND METHODS
Pre-experimental study was conducted with twenty samples at cardio thoracic intensive care unit after obtaining an authorized setting permission from the hospital. Convenience sampling technique was adopted to select the samples who met the inclusion criteria. Patients with more than 18 years of both male and female undergone elective coronary artery bypass graft, having hearing, speaking and cognitive ability were included for the study and the exclusion criteria were patient who had the habit of smoking, history of cerebrovascular accident, renal dysfunction, previous open heart of pulmonary surgery, cardiovascular instability or an aneurysm and on the treatment of immunosuppressive treatments during the 30 days prior to surgery. St. Grorge Respiratory Assessment scale was also used to select the participants. This scale score ranging from 0-100 with lowest score indicating low limitations in respiratory function. Participants were explained about the purpose of the study. Informed consent was obtained after assuring the con idence. Demographic variables were collected by using structured questionnaire and assessed the physiological parameters such as oxygen saturation, respiratory rate, heart rate, systolic and diastolic blood pressure. Followed by an active cycle of breathing technique was administered to the participants twice a day for 3 days from the irst post-operative day onwards. This technique consists of breathing control, deep breathing exercise and huf ing. Participants were instructed to close their eyes and take breathe in and out through the nose / mouth and gradually reduce breathes slower. Deep breathing exercise was continued by the participants for 3-5 times followed by 1-2 medium volume huf ing was performed. The total duration for each session was 10-15 minutes. Physiological parameters was assessed each day before and after the intervention and post-test value was taken for analysis. Post-operative complications was assessed at the end of 3 rd day of intervention by using the checklist contains the pulmonary complications due to surgery. Con identiality was maintained throughout the study. Data were analyzed by both descriptive and inferential statistics using SPSS statistical package.

RESULTS AND DISCUSSION
The present study observed that majority 9 (45%) were in the age group of 31 -60 years and 14(70%) were and doing heavy work. More than 60% had the habit of smoking. Around 15(75%) had no past history of respiratory asthma and only 5(25%) had the past history of respiratory asthma as depicted in Table 1.
The Table 2 shows that the pretest mean score of oxygen saturation was 98.65 ±1.19 and post test score mean and standard deviation of Day 1, Day2 and Day 3 was 99.32 ± 1.95, was 99.75±1.25 and 99.85±1.50 respectively. The calculated repeated measures ANOVA F value of F = 15.18 was found to be statistically signi icant at the level of P<0.05 which clearly indicates that there was signi icant difference in the level of oxygen saturation.Regarding respiratory rate, the pretest mean and SD was 24.65±3.92 and post test score mean and standard deviation was 23.27 ± 1.76, 21.70±1.68 and 20.93±1.27 in Day 1, Day2 and Day 3 respectively. The pre-test and post-test score of mean and SD values were calculated by repeated measures of ANOVAand found value of F = 5.64 was revealed be statistically signi icant at the level of P<0.001. The pre-test mean score of heart rate was 88.20±3.92 and post test mean and standard deviation of Day 1, Day2 and Day 3 was 90.97± 7.51, was 91.37±6.90 and 91.65±5.75 respectively. The calculated repeated measures of ANOVA found the value of F=0.672 which shows signi icantdifference in the level of heart rate. The systolic and diastolic blood pressure score of pre-test and post-tests mean value were also calculated by repeated measures ANOVA which found to be no signi icant difference in different level at the level of p<0.05.
The Table 3 indings revealed that the active cycle breathing technique on physiological parameters in the study group was found effective in improving the oxygen saturation and heart rate. The respiratory rate shows highly signi icant improvement than the oxygen saturation and heart rate at the level of p<0.001. However there was no signi icant improvement was found in systolic and diastolic blood pressure at the level of p<0.05. Table 4 depicts that only person (10%) had developed the pulmonary complications of pleural effusion and pneumothorax followed by Coronary artery bypass surgery. None of them had any oth-ers complications such as pneumonia, prolonged mechanical ventilation, atelectasis, pulmonary edema, respiratory failure and acute respiratory distress syndrome.
Coronary artery bypass surgery procedure potentially causes the increased incidence of postoperative pulmonary complications. Changes in the pulmonary function following open heart surgery have been well reported by researchers and contribute considerably to post-cardiac morbidity and mortality. There are routine physiotherapy techniques which help to improve the pulmonary function from immediate post-operative period onwards. Amongst Active cycle breathing technique in as excellent breathing exercise because of a signi icant piece of the clearance mechanism of either an episode or a cough which diminishes the atelectatic area and increase ventilation (Frownfelter and Dean, 2012;Derakhtanjani et al., 2019). Hence the current was conducted to determine the effectiveness of active cycle breathing technique on pulmonary complications and found that there is an improvement in physiological parameters which inturn reduces the postoperative pulmonary complication. The respiratory rate shows highly signi icant improvement than the oxygen saturation and heart rate. These indings of research supported by Ahmad et al who found that ACBT and routine physiotherapy had related outcome on arterial oxygenation, heart rate, and pain discernment following CABG procedure and furthermore it is seen that on the subsequent day there was rise up of the respiratory rate to an unusual span (Savci et al., 2006). However in current study the pain level was not measured and respiratory rate was also stable with ACBT. Further, Savci et al who demonstrated adequacy of incentive spirometer and active cycle of breathing techniques following CABG and watched the improved blood vessel oxygenation from the initial day of post-operatively and following a 5 th day of the treatment, utilitarian limit was very much protected with the utilization of ACBT (Monisha and Muthukumar, 2018). These indings con irmed the result of other study by Monisha et al.,201 who also found that ACBT improves utilitarian limit from the 6th to ninth day post-operatively and useful limit was very much protected with the utilization of ACBT after a 5-day treatment (Lamuvel et al., 2016). In another study by Maria et al who reasoned that ACBT improves the lung function in abdominal surgeries however there is increasingly critical improvement in pneumonic capacity when ACBT is given along with transcutaneous electrical nerve stimulation (Wange et al., 2016). Similarly Wang et al who found that active cycle of     (Syropoulos et al., 2016) . In contrast with previous studies Syropoulos et al reported that ACBT was related with critical increments in the SPO2 from the third postoperative day, yet was no greater at forestalling aspiratory intricacies than the typical postoperative physiotherapy routine (Çırak, 2015). There are limited studies which supported the present study indings. These study indings are contrast with the study inding by Cirak et al who shown that physiotherapy may help patients in high-hazard bunch for quicker recuperation after CABG and is progressively basic in high-chance patients to get comparable outcomes as in low-risk group (Grammatopoulou et al., 2010). Many studies which proven that ACBT helps to reduce the pain perception and this inding seems to con irm the indings of a study by Grammatopoulou et al who revealed that ACBT appeared to reduce pain in patients with rib fractures. Though there is great strengths of improvement in oxygen saturation, respiratory rate, heart rate and decrease in the occurrence of pulmonary complications after CABG without any adverse effects. However this study has limited to assess the pain, pulmonary function test such as forced vital capacity, forced expiratory volume, arterial blood gas analysis. Hence this study is recommended to conduct the study adopting true experimental design to analyze these parameters with large number of sample. Similarly comparative study also may be done to compare the ACBT other complementary breathing exercise as well compare the effectiveness between cardiothoracic and thoraco-abdominal surgery.

CONCLUSIONS
This study inding concluded that ACBT is effective in preventing pulmonary complications and can be administered routinely after CABG as all the physiological parameters within the clinical range during the intervention phase. ACBT is also a safe method as it is done under the direct supervision of investigators.