Download Inspiratory muscle training can benefit all the three disciplines of a

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1
NAME AND ADDRESS OF THE
CANDIDATE
SWATI SASWATI BAG
Department of Physiotherapy
Florence College of Physiotherapy
2
NAME OF THE INSTITUTION
Department of Physiotherapy
Florence College Of Physiotherapy
3
COURSE OF STUDY AND
SUBJECT
Master of Physiotherapy
4
DATE OF ADMISSION TO
COURSE
11th June, 2013
5
TITLE OF THE STUDY
EFFECTIVENESS OF INSPIRATORY
MUSCLE TRAINING IN PATIENTS OF
CABG USING SPIROMETRY AND THE 6MINUTE WALK TEST
(Cardio-respiratory Disorders)
6. BRIEF RESUME OF INTENDED WORKS:
6.1 NEED FOR STUDY
Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow
to the heart. Surgeons use CABG to treat people who have severe coronary heart disease
(CHD). CABG is one treatment for CHD. During CABG, a healthy artery or vein from the
body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein
bypasses (that is, goes around) the blocked portion of the coronary artery. This creates a new
path for oxygen-rich blood to flow to the heart muscle.
Postoperative pulmonary complications (PPCs) after coronary artery bypass graft
(CABG) surgery are a major source of morbidity and mortality, and increase length of
hospital stay and resource utilization. The prehospitalization period before CABG surgery
may be used to improve a patient's pulmonary condition. The efficacy of preoperative
inspiratory muscle training (IMT) in reducing the incidence of PPCs in high-risk patients
undergoing CABG surgery has not yet been determined.
PROBLEM LIST AFTER CABG:
1.
2.
3.
4.
5.
6.
Limited mobility
Fatigue
Post operative pulmonary complications
Functional limitations
Breathing difficulties
Inspiratory muscle weakness
Inspiratory muscle training is defined as a course of therapy consisting of a series of
breathing exercises that aim to strengthen the bodies’ respiratory muscles making it easier for
people to breathe. Inspiratory muscle training is normally aimed at people who suffer from
asthma, bronchitis, emphysema and COPD. However, many people adopt IMT as part of
their fitness training, as this training is designed to strengthen the muscles used for breathing.
This is done through a series of controlled breathing exercises. Studies have shown that
regular IMT can increase a person’s endurance during cardiovascular exercise or sports
activities such as running and cycling.
The respiratory muscles need to be trained because during exercise the body’s
demand for oxygen increases and our breathing volume or ventilation must also rise to cope
with the oxygen increase. For this to work numerous muscles surrounding the lungs need to
contract in an exceedingly coordinated manner. As the intensity of the exercise increases,
these respiratory muscles must contract more forcefully and more rapidly to keep pace with
the body’s substantial increase in metabolism.
Naturally, everyday breathing is too easy to have a conditioning effect on
the respiratory muscles, but when inhalation and/or exhalation takes place against resistance
with a respiratory muscle training device, these muscles may be taxed even more than they
are while walking, swimming, bike and run. As a result, they become stronger and more
fatigue-resistant and therefore less limiting on exercise performance.
Inspiratory muscle training can benefit all the three disciplines of a exercise
protocol. Where using a breathing training device will be of benefit as when performing
exercise, the body demands more oxygen.
Generally while performing spirometry test, the patient is asked to take the deepest
breath they can ,(i.e PImax), and then exhale into the sensor as hard as possible, for as long as
possible, preferably at least 6 seconds. As Inspiratory muscle strength is assessed by
measuring the maximal inspiratory mouth pressure(PIP or PImax) at residual volume. Peak
inspiratory pressure (PIP / PImax) is the highest level of pressure applied to
the lungs during inhalation, this way this maneuver helps to improve a person’s PIP(peak
inspiratory volume) During the training period, the training group continued to show a small
increase in the PI,max, which suggests that there is significant role or effectiveness of
spirometry in improving inspiratory muscle strength.
The 6MWT was developed in 1963 by Balke to evaluate functional capacity.
The original purpose of the six minute walk was to test exercise tolerance in chronic
respiratory disease and heart failure. The exercise tolerance test is mainly based on lung
volumes, which mostly included FVC and FEV1.
The reduction in FVC and FEV1 weakens the coughing and the movement of
secretions, which can lead to early closure and obstruction of small airways that predispose to
microateletasias and hence reduction in oxygenation, which can increase the length of
hospital stay. This demonstrates that the measure of deambulation ability of the patient is
used by some professionals as the purpose of treatment, since this parameter represents better
the individual's functional capacity [14,15, 16]. Thus, one can justify, in our study, the
significant negative correlation of the 6-MWT distance walked by the patient with the time of
hospital stay, because it suggests that the patient who presents more deambulation ability has
a functional capacity more suitable for hospital discharge, reflecting better the functionality
than the lung function alone. The significant correlation of FVC and FEV1 with the 6-MWT
also suggests that deambulation ability may better reflect overall functional capacity and can
be justified by the fact that greater deambulation capacity is associated with higher
stimulation of ventilation, increased pulmonary perfusion and detachment of secretions and
oxygenation improvement17.
6.2 REVIEW OF LITERATURE:
 Relationship of postoperative walk test and lung function with the length of
heart surgery hospital stay (Elayne Kelen de OliveiraI; Vinicius Zacarias
Maldaner da SilvaII; Aída Luiza, OCT/DEC 2009)
A prospective cohort with 18 patients was performed, being 8 males and 10 females,
with age above 40 years (mean 64.89 ± 6.95 years). Patients where admitted for
coronary artery bypass graft surgery and/or valve replacement. To characterize the
pulmonary function, patients had undergone spirometry in preoperative and at 5th
postoperative day. In the latter period was also performed a test for 6 minutes walk
(6MWT) to characterize the deambulation ability. The results suggested that patients
with increased postoperative deambulation capacity have a shorter time of hospital
stay and it also suggests that the distance in the 6MWT can better represent the
functional capacity of these patients than lung function alone.
 Inspiratory muscle training improves tidal volume and vital capacity after
CABG surgery (Matheus GB, Dragosavac D, Trevisan P, Costa CE, Lopes MM,
Ribeiro GC. Hospital e Maternidade Celso Pierro, Pontifícia Universidade
Católica de Campinas, Campinas, SP, Brasil, 2012 Jul-Sep;27(3):362-9 ).
A randomized study with 47 patients undergoing coronary artery bypass
grafting with cardiopulmonary bypass. They were divided into study group (SG) 23
patients and control group (CG) 24 patients, respectively. The study group underwent
physical therapy and inspiratory muscle training with threshold IMT® and CG
underwent conventional physiotherapy. We compared the maximal respiratory
pressures (MIP and MEP), tidal volume (TV), vital capacity (VC) and peak expiratory
flow (peak flow) preoperatively (Pre-OP), 1st (PO1) and 3rd (PO3) postoperative day.
It therefore concluded that the patients undergoing cardiac surgery experience reduced
ventilatory capacity and respiratory muscle strength after surgery. Muscle training
was performed to retrieve TV and VC in the PO3, in the trained group.
 Longitudinal evaluation the pulmonary function of the pre and postoperative
periods in the coronary artery bypass graft surgery of patients treated with a
physiotherapy protocol ( Moreno AM, Castro RR, Sorares PP, Sant' Anna M,
Cravo SL, Nóbrega AC, 2011).
Forty-two volunteers with an average age of 63 ± 2 years were included
and separated into three groups: healthy volunteers (n = 09), patients with CAD (n =
9) and patients who underwent CABG (n = 20). Patients from the CABG group
received preoperative and postoperative evaluations on days 3, 6, 15 and 30. Patients
from the CAD group had evaluations on days 1 and 30 of the study, and the healthy
volunteers were evaluated on day 1. Pulmonary function was evaluated by measuring
forced vital capacity (FVC), maximum expiratory pressure (MEP) and Maximum
inspiratory pressure (MIP). The results showed that after CABG, there was a
significant decrease in pulmonary function (p < 0.05), which was the worst on
postoperative day 3 and returned to the preoperative baseline on postoperative day
30.Pulmonary function decreased after CABG. Pulmonary function was the worst on
postoperative day 3 and began to improve on postoperative day 15. Pulmonary
function returned to the preoperative baseline on postoperative day 30.
 Freitas ER, Soares BG, Cardoso JR, Atallah AN.UNOPAR / Centro Cochrane
do Brasil, Physical Therapy Department, Rua Belo Horizonte, LONDON,
2012;9:CD004466)
A randomized controlled trial was performed to assess the effects of incentive
spirometry for preventing postoperative pulmonary complications in adults
undergoing CABG comparing incentive spirometry with any type of prophylactic
physiotherapy for prevention of postoperative pulmonary complications in adults
undergoing CABG. Four trials with 443 participants contributed to this review. There
was a significant difference in pulmonary complications (atelectasis and pneumonia)
between treatment with incentive spirometry and treatment with positive pressure
breathing techniques (continuous positive airway pressure (CPAP), bilevel positive
airway pressure (BiPAP) and intermittent positive pressure breathing (IPPB)) or
preoperative patient education. Patients treated with incentive spirometry had better
pulmonary function and arterial oxygenation. Individual small trials suggest that there
is benefit from incentive spirometry in reducing pulmonary complications and in
decreasing the negative effects on pulmonary function in patients undergoing CABG.
 Comparision between Deep Breathing Exercises and incentive spirometry after
CABG surgery (Renault JA, Costa-Val R, Rosseti MB, Houri Neto M., Santa
Casa de Misericórdia of BeloHorizonte - Belo Horizonte, MG, Brazil, 2009 AprJun;24(2):165-72. )
Thirty six patients in CABG postoperative period underwent thirty minutes of noninvasive ventilation during the first 24 hours after extubation and were randomly
shared into two groups as following: DBE (n=18) and IS (n=18). The spirometric
variables were assessed on the preoperative period and seventh postoperative day
(POD). The respiratory muscle strength and oxygen saturation were assessed on the
preoperative period, first, second and seventh POD. The groups were considered
homogeneous in relation to the demographic and surgical variables. It has been noted
fall in the values of FVC and FEV(1) between the preoperative period and the seventh
POD, but without significant differences between groups. The maximal respiratory
pressures showed drop in the first POD but with and partial recovery until the seventh
POD, also without significant differences between groups. The oxygen saturation was
the only variable that was completely recovered on the seventh POD, also without
significant differences between groups. Therefore it was concluded that there were
significant differences in maximal respiratory pressures, spirometric variables and
oxygen saturation in patients undergone deep breathing exercises and flow-oriented
incentive spirometry after coronary artery bypass grafting.
 Bilag til artiklen: Fysioterapi efter hjerteoperation og i forbindelse med
cancerrehabilitering Stationary cycling is as effective as walking in phase i
cardiac rehabilitation: a randomized-controlled trial (Hirschhorn A., Richards
D., Mungovan S., Morris N., Adams L, 2012)
A study was done to determine if cycling as effective as walking in Phase I cardiac
rehabilitation (CR) after coronary artery bypass graft surgery (CABG). Consecutive
patients (n=64) awaiting first-time, non-emergency CABG at Westmead Private
Hospital between August 2008 and July 2009 (mean age: 66±9 years,57 men, 7
women) participated in the study. Patients were randomly allocated to receive Phase I
CR comprising either physiotherapy-supervised, moderate intensity stationary cycling
or walking exercise. Tenminute exercise sessions were scheduled twice-daily from the
third postoperative day until hospital discharge. Primary outcomes, six-minute walk
distance (6MWD) and six-minute cycle work (6MCW), were measured preoperatively
and at hospital discharge by a physiotherapist blinded to group allocation. Secondary
outcomes were postoperative length of hospital stay (LOS) and compliance with
exercise training. For all completed training sessions the following data were
recorded: i) cycle work or walk distance as applicable, and ii) exercise heart rate (HR)
and blood pressure (BP).As a result, stationary cycling (n=32) and walking (n=32)
exercise groups were well matched at baseline for demographic/anthropometric
variables. Stationary cycling provides a clinically effective alternative to walking
exercise in Phase I CR after CABG.
 Jonsson M., Westerdahl E.
A study with the aim of determining the relationship between lung function
and postoperative self-reported physical activity after cardiac surgery was done. As
lung function, measured with spirometry, declines with decreasing level of physical
activity in all age groups in the general population. However, no studies have been
published where the relationship between physical activity and lung function after
cardiac surgery has been investigated. A sample of 76 patients undergoing cardiac
surgery was identified and followed up 2 months postoperatively. Physical activity
level was quantified using a categorical question about regular physical activity at
work and during leisure time.Lung function was measured by spirometry. The
measurements were made preoperatively and 2 months postoperativel. The data were
analyzed using descriptive statistics. A sample of 63 male and 13 female patients was
followed up 2 months after cardiac surgery. This study demonstrates that physical
activity has an impact on postoperative lung function. Besides the well-established
positive cardiovascular effects of physical activity, our result shows that physical
activity also has a beneficial effect on the pulmonary recovery after cardiac surgery.
To improve pulmonary recovery after cardiac surgery, patients would benefit from
engaging in regular exercise.
 Effects of inspiratory muscle training compared with active cycle of breathing
techniques and usual care in coronary artery bypass surgery
(Savci S., Arikan H., Saglam M., Inal-Ince D, Degirmenci B., Turan H.N.,
Demircin T, 2011 )
A single-blinded, randomized controlled trial study was performed. The aim of
the study was to determine the effects of inspiratory muscle training (IMT) and
compared with the active cycle of breathing techniques (ACBT) and usual care on
postoperative pulmonary function, respiratory muscle strength, and functional
capacity among patients with coronary artery bypass graft (CABG) surgery.
Cardiopulmonary dysfunction is common in patients with post-CABG surgery. Chest
physiotherapy and mobilization are frequently used treatment techniques by
physiotherapist to prevent post-operative pulmonary complications. The IMT can be
implemented in the perioperative care of CABG surgery.Seventy-three patients
undergoing CABG surgery were randomly assigned to one of the three groups: IMT
group (n=23), ACTB group (n=25), and usual care (control) group (n=25)..
Pulmonary function testing, respiratory muscle strength, and 6- minute walk test
(6MWT) were assessed preoperatively and the fifth day after the surgery. Subjects in
all groups received the same usual care once daily. The ACBT and IMT group trained
daily, 2 times per day for 10 days (5 days in preoperative period, 5 days in
postoperative period). The ACBT consisted of 1-2 breathing control breaths, three
thoracic expansion exercises followed by a 3-second breath hold at the end of deep
inspiration, and the forced expiration technique. Each IMT session consisted of 30
minutes of inspiratory muscle training under the supervision of a physiotherapist. The
patients were trained to use an inspiratory threshold-loading device.
The patients started breathing at a resistance equal to 15% of their maximal
inspiratory pressure. The resistance was increased incrementally between 15 and 45%
based on patients' tolerance in the following days. There were no significant
differences in age, gender, and surgical procedures among the groups. Inspiratory and
expiratory muscle strength, and six-minute walk distance were significantly higher in
IMT group compared with the other techniques. Intensive care unit stay was
significantly shorter in IMT group compared with the other techniques. Inspiratory
and expiratory muscle strength were also significantly higher in the ACBT group
compared with the control group. Thus it was concluded that IMT results in a faster
recovery of inspiratory muscle strength and functional capacity compared with ACBT
and usual care after CABG. Therefore improvements in functional capacity and
respiratory muscle strength may lead patients to participitate activities of daily living.
Further study is needed to determine the effects of longer inspiratory muscle training
on postoperative pulmonary complications and disease specific quality of life in
patients undergoing CABG with a wider sample size.
 Pre-operative inspiratory muscle training preserves postoperative inspiratory
muscle strength following major abdominal surgery - a randomised pilot study.
(Kulkarni SR, Fletcher E, McConnell AK, Poskitt KR, Whyman MR, , 2010
Nov;92(8):700-7).
A pilot study was done to assess the effect of pre-operative inspiratory
muscle training (IMT) on respiratory variables in patients undergoing major
abdominal surgery. Respiratory muscle strength (maximum inspiratory [MIP] and
expiratory [MEP] mouth pressure) and pulmonary functions were measured at least 2
weeks before surgery in 80 patients awaiting major abdominal surgery. Patients were
then allocated randomly to one of four groups (Group A, control; Group B, deep
breathing exercises; Group C, incentive spirometry; Group D, specific IMT). Patients
in groups B, C and D were asked to train twice daily, each session lasting 15 min, for
at least 2 weeks up to the day before surgery. Outcome measurements were made
immediately pre-operatively and postoperatively. It concluded that pre-operative
specific IMT improves MIP pre-operatively and preserves it postoperatively. Further
studies are required to establish if this is associated with reduced pulmonary
complications.
 Preoperative intensive inspiratory muscle training to prevent postoperative
pulmonary complications in high-risk patients undergoing CABG surgery: a
randomized clinical trial (Hulzebos EH, Helders PJ, Favié NJ, De Bie RA,
Brutel de la Riviere A, Van Meeteren NL. Department of neurology and
neuroscience, 2006 Oct 18;296(15):1851-7) .
A single-blind, randomized clinical trial conducted at the University
Medical Center Utrecht, Utrecht, the Netherlands, with enrollment between July 2002
and August 2005. Of 655 patients referred for elective CABG surgery, 299 met
criteria for high risk of developing post operative pulmonary complications, of whom
279 were enrolled and followed up until discharge from hospital To evaluate the
prophylactic efficacy of preoperative Inspiratory Muscle Training on the incidence of
PPCs in high-risk patients scheduled for elective CABG surgery. Patients were
randomly assigned to receive either preoperative IMT (n = 140) or usual care (n =
139). Both groups received the same postoperative physical therapy. The outcome
measures included less incidence of PPCs, especially pneumonia, and duration of
postoperative hospitalization. Both groups were comparable at baseline. After CABG
surgery, PPCs were present in 25 of 139 patients in the IMT group and 48 of 137
patients in the usual care group. Pneumonia occurred in 9 of 139 patients in the IMT
group and in 29 of 137 patients in the usual care group. Median duration of
postoperative hospitalization was 7 days (range, 5-41 days) in the IMT group vs 8
days (range, 6-70 days) in the usual care group. Thus it is concluded that preoperative
IMT reduced the incidence of PPCs and duration of postoperative hospitalization in
patients at high risk of developing a pulmonary complication undergoing CABG
surgery.
 Reference values for the 6-minutes walking test in healthy subjects 20-80
yearsold (Osses A R, Yáñez V J, Barría P P, Palacios M S, , Lisboa B C.
Chile,2010).
A group of 175 healthy volunteers aged 20-80 years (98 women) were
examined with normal spirometry and without history of respiratory, cardiovascular
or other diseases that could impair walking capacity. The test was performed twice
with an interval of 30 min. Heart rate, arterial oxygen saturation (with a pulse
oxymeter) and dyspnea were measured before and after the test. walking distance was
576 ± 87 m in women and 644 ± 84 m in men (p < 0.0001). For each sex, a model
including age, height and weight produced 6MWD prediction equations with a
coefficient of determination (R²) of 0.63 for women and 0.55 for men. The results
provided reference equations for 6MWD that are valid for healthy subjects between
20 and 80 years old.
 Anthony Errol Aqui, M.Sc. Candidate, Wilfrid Laurier University, 2008
A study was performed to determine if inspiratory muscle training
(IMT) would result in increased inspiratory muscle strength, reduced perception of
exertional dyspnea, and improved measures of maximal exercise effort in an athlete
with exercise-induced paradoxical vocal fold motion (PVFM). The participant, an 18year-old woman, had a 2-year history of acute dyspnea with exertion during soccer
games. Spirometry, transnasal flexible laryngoscopy, and patient history supported a
PVFM diagnosis. The ABAB within-subject withdrawal design study comprised IMT
treatment and withdrawal phases, each lasting 5 weeks. The participant trained 5 days
per week, completing five sets of 12 breaths at 75% maximum inspiratory pressure
(MIP) per session. Data consisted of MIP, exertional dyspnea ratings, and maximal
exercise measures. IMT resulted in increased MIP and decreased dyspnea ratings
across both treatment phases. No change in MIP or dyspnea ratings occurred in
response to treatment withdrawal. The maximal exercise test revealed minimal
changes across phases. At end of the study, the participant reported experiencing no
PVFM symptoms when performing the outcome measurement tasks and when playing
soccer. Transnasal flexible laryngoscopy, after strenuous exercise and during rapid
breathing and phonation tasks, revealed normal laryngeal findings. The findings
suggest that IMT may be a promising treatment approach for people with exerciseinduced PVFM.
6.3OBJECTIVES OF THE STUDY
The main purpose of the study is
To study the effectiveness of inspiratory muscle training in CABG patients using
spirometry and six minute walk test.
HYPOTHESIS:
Null Hypothesis:
There is no significant effectiveness in the application of training of inspiratory muscles
using spirometry and six minute walk test.
Alternate Hypothesis:
There may be significant effectiveness of inspiratory muscle training to improve
inspiratory muscle strength in CABG patients using spirometry and six minute walk test.
7. MATERIALS AND METHODOLOGY
7.1 SOURCE OF DATA
Ravi Kirloskar Memorial Hospital, Bangalore
Patients fulfilling the inclusion and exclusion criteria are selected.
7.2 METHOD OF COLLECTION OF DATA
STUDY DESIGN:
This is a study of Pre-test and Post-test experimental research design
STUDY SAMPLE DESIGN:
Selection of samples is done by random sampling method
TYPE OF STUDY:
Comparative study
SAMPLE SIZE
30 subjects were divided into two groups. Group A will be asked to perform the
spirometry test using a device called a spirometer.
Group B will be asked to perform the six minute walk test which emphasizes the
subject’s mobility performance.
INCLUSION CRITERIA:
 Patients undergone CABG procedure (after they are shifted from ICU to general
wards)
 Age: between 18-65 years of age
 Gender: both male and female
 Able to understand instructions given by physical therapist and doctors
Exclusion criteria:
We excluded patients who had a history of atrial fibrillation, chronic heart failure,
utilization of intra-aortic balloon pump, mechanical ventilation longer than 24 hours, acute
myocardial infarction within 6 months prior to the surgery, autonomic neuropathy,
neurological disorders and pulmonary disease.
7.3 INTERVENTION/ASESSMENT TO BE DONE
Materials used:
1.
2.
3.
4.
5.
6.
7.
8.
Examination table
Bed sheet
Pillow
Spirometer
A 30 meter, pre-measured flat walking area with interval markings every three meters.
Cones or brightly coloured tape to mark boundaries of the course
Watch or timer to time 6 minutes
Chair available if patients need to rest during testing
METHODOLOGY:
PROCEDURE:
30 subjects based on inclusion and exclusion criteria will be included in the study.
The subjects will be randomly allocated into two groups. . Group A will be asked to perform
the spirometry test using a device called a spirometer.
Group B will be asked to perform the six minute walk test which emphasizes the
subject’s mobility performance.
Pre-test and Post-test measures will be taken according to the performances given
by each subject.
All the subjects in the CABG group had a preoperative evaluation and orientation in
accordance to the physiotherapy procedures. After surgery, they had physiotherapy sessions
twice a day for 30 minutes up to postoperative day 6 or until discharge from the hospital.
EXERCISE REGIMENS:
The exercise regimen will be conducted over a 6th post operative day or until
discharge from the hospital. The physiotherapy exercise sessions will be no longer than 30
minutes, twice a day. Subjects in Group A will be treated using the same protocol as Group
B.
Six minute walk test:
The primary outcome is the distance covered in meters or converted measure (such as
feet) over 6 minutes. A lower score (reflecting less distance covered in 6 minutes) indicates
worse function.
The six minute walk distance in healthy adults has been reported to range from
400m to 700m. Age and sex-specific reference standards are available and may be helpful for
interpreting 6MWT scores for both healthy adults and those with chronic diseases.
Method
This is ideally conducted in an enclosed, quiet hallway by a single administrator. The
patient is given instructions. He/she is asked to walk as far as possible in six minutes. The
individual is allowed to self-pace and rest as needed. The walkway length is 30meter corridor
with cones placed at the beginning and end of the 30 meter boundry to indicate turns. A total
number of 3 trials is performed. The total time to administer/complete the six minute test is
an average of 15minutes less.
SPIROMETRY
Spirometry is a simple breathing painless test that can often be done in your
doctor’s office or in a nearby clinic. The entire test usually takes less than 10minutes,
although sometimes it is repeated after taking a puffer medication.
The patient is asked to breathe through a mouthpiece while wearing a nose clip.
The tester will coach you to take in as big a breathe as possible. The patient will then blast the
air out as fast as you can until your lungs are completely empty. The patient may then be
asked to take a deep breath in again. He will do this three times or more to make sure the
results are accurate. He may also be given medications to breathe in. The test would then be
repeated to show if his lungs have responded to the medication.
Preparing a patient for test:




No smoke for one hour before test
No drink alcohol within four hours of test
No eating of large meal within two hours of test
Wear loose clothing

If the patient is on puffer medications, he/she may be asked not to take them for few
hours before spirometry.
Procedure:
1. Breathe in fully (the lungs must be completely full)
2. Seal the lips and teeth tightly around the mouth piece and then....
3. Blast the air out as fast and as long as possible till the lungs are completely empty
(10sconds is optimal), and then
4. Breathe in fully again without removing the mouthpiece from the patients mouth
5. Repeat the test until 3 acceptable and reproducible tests/results are obtained (up to a
suggested maximum of eight efforts)
6. The highest FEV1 and FVC should be reported (along with other test measurements
dictated by the ordering physician), even if they are from separate blows. But must be
from the same overall series of tests of the same day.
*Nose clips should be used on all the patients to prevent loss of measured volume through
nose.
Outcome measures:
Spirometry tells us if our lungs are functioning normally. It does this through
different breathing measurements. Some of the most common measurements include:
Forced Vital Capacity (FVC)- The largest amount of air a person can blow out after he/she
takes their biggest breath in.
Forced Expiratory Volume ( FEV1) - The amount of air a person can blow out of his/her
lungs in the first second.
If the amount of air the person blow out in the first second is low, he/she might have
lungs disease such as asthma, COPD, atelactesis, etc.
If the person has already been diagnosed with asthma or COPD, spirometry can be
more usefull to determine if their current treatment is working.
7.4 ETHICAL CLEARANCE:
Ethical clearance has been obtained from the ethical committee of the institution.
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van der Schaaf M.)
3. Troosters T, Gosselink R, Decramer M. Six minute walk distance in healthy elderly
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4. Redelmeier, 1997
5. Respiratory muscle training in healthy humans: resolving controversy (A.K.Mc Connell,
L.M.Romer)
6. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary
complications in high risk patients undergoing CABG procedure- a ramdomized clinical
trial (Eric H J Hulzebos, PT MSc; Paul J.M.Helders, PT PhD; Nine J. Favie, PT MSc)
7. INSPIRATORY MUSCLE FATIGUE FOLLOWING MODERATEINTENSITY
EXERCISE IN THE HEAT (James S. Williams 1, 2 �, Kendra A. O’Keefe 1 and Lee
T. Ferris 2 Department of Health, Exercise, and Sport Sciences and 2 Department of
Physiology, Texas Tech University/TTU Health Sciences Center, Lubbock, TX, USA)
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and COPD (Alison K. Mc Connell, 2005)
9. American Thoracic Society/European Respiratory Society Statement on Pulmonary
Rehabilitation ( Linda Nici, Claudio Donner, Emiel Wouters, Richard Zuwallack)
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com derivação intraluminal. Rev Col Bras Cir. 1998;25(6):363-8
15. Bellinetti LM, Thomson JC. Respiratory muscle evaluation in elective thoracotomies
and laparotomies of the upper abdomen. J Bras Pneumol. 2006;32(2):99-105
16. Macchi C, Fattirolli F, Lova RM, Conti AA, Luisi MM, Intini R, et al. Early and late
rehabilitation and physical training in elderly patients after cardiac surgery. Am J Phys
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17. Papaspyros S, Uppal S, Khan SA, Paul S, O'Regan DJ. Analysis of bedside
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randomised clinical trial. Eur J Cardiothorac Surg. 2008;34(5):1022-6
9
SIGNATURE OF THE CANDIDATE
10
REMARKS FOR GUIDE
11.1 NAME AND DESIGNATION OF GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF DEPARTMENT
11.6 SIGNATURE
12
REMARKS OF THE CHAIRMAN AND
PRINCIPAL
12.1 SIGNATURE