Prevention of Postoperative Pulmonary Complications
Through Respiratory Rehabilitation: A Controlled Clinical
Study
Soledad Chumillas, MD, Jos~ L. Ponce, AID, Fernando Delgado, MD, Vicente Viciano, AID,
Miguel Mateu, PT
ABSTRACT. Chumillas S, Ponce JL, Delgado F, Viciano V,
Mateu M. Prevention of postoperative pulmonary complications
through respiratory rehabilitation; a controlled clinical study.
Arch Phys Med Rehabil 1998;79:5-9.
Objective: To investigate the efficacy of respiratory rehabili-
tation in preventing postoperative pulmonary complications
(PPC) and to define which patients can benefit.
Design: A randomized clinical trial.
Setting: A public hospital.
Patients: Eighty-one patients who had upper abdominal sur-
gery were distributed into two homogeneous groups: control (n
= 41) and rehabilitation (n = 40).
Intervention: Breathing exercises in the rehabilitation group.
Main Outcome Measures: Preoperative and postoperative
clinical evaluation, spirometry, arterial gasometry, and simple
chest X-rays.
Results: The incidence of PPC was 7.5% in the rehabilitation
group and 19.5% in the control group; the control group also had
more radiologic alterations (p = .01). Stratified PPC analysis did
not reveal significant differences between groups. However,
high- and moderate-risk patients in the rehabilitation group had
fewer PPC. Multivariate analysis showed a greater PPC risk
associated with pulmonary history (p = .02) and duration of
surgery longer than 120rain (p = .03), while rehabilitation ex-
erted a protective effect (p = .06). Significant postoperative
decreases in pulmonary volumes and arterial gas values were
recorded in both groups, without significant differences.
Conclusions: Respiratory rehabilitation protects against PPC
and is more effective in moderate- and high-risk patients, but
does not affect surgery-induced functional alterations.
© 1998 by the American Congress of Rehabilitation Medicine
and the American Academy of Physical Medicine and Rehabili-
tation
p ULMONARY FUNCTION is commonly altered after sur-
gery, 1 particularly in patients who have had chest or upper
abdominal surgery. The physiological changes observed are di-
rectly related to anesthesia (general or regional) and to the type
of incision and surgical technique employed, and are reflected
by decreases in total pulmonary capacity and pulmonary vol-
umes and by a parallel decrease in Pa02.2-4
From the Departments of Rehabilitation (Dr. Chumillas) and Surgery (Dr.
Viciano), Lluls Alcanyfs Hospital, Xhtiva, Valencia; Departments of Surgery (Dr.
Delgado) and Rehabilitation (Mr. Mateu), Dr. Peset Hospital, Valencia; and De-
partment of Surgery (Dr. Ponce), Valencia University Medical School, Spain.
Submitted for publication October I0, 1996. Accepted in revised from February
13, 1997.
No commercial party having a direct financial interest in the results of the
research supporting this article has or will confer a benefit upon the authors or
upon any organization with which the authors are associated.
Reprint requests to Dr. Maria Soledad Chumillas Luj~in, Servicio de Rehabilita-
cidn, Hospital Lluls Alcanyis, Carretera Xb.tiva-Silla, Kin. 2, 46800-Xativa, Spain.
© 1998 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003 9993/98/7901-423053.00/0
These functional alterations are in turn implicated in the de-
velopment of postoperative pulmonary complications (PPC),
which are among the foremost causes of morbidity and mortality
among surgical patients. 4'5 The reported frequency of PPC is
highly variable, 6-9 ranging from 6% to 76% according to how
complications and the methods used to evaluate them have been
defined, and how the studies were controlled.
Breathing exercises have commonly been used to increase
pulmonary volume and improve gas exchange and ventilation
distributionJ ° Diaphragmatic, segmental, and costal respiratory
exercises, as well as sustained maximal inspiration, may allevi-
ate surgically induced alterations such as diminished diaphrag-
matic mobility and restrictive pulmonary changes.m'l~
Most studies on the effects of respiratory rehabilitation have
had methodological defects that weaken their conclusions. Re-
sults from studies done after the Conferences of the National
Heart and Lung Institute in 1974 and 1979, however, suggest
that respiratory rehabilitation, physical therapy, and mechanical
devices may exert a beneficial effect on the postoperative course
of patients who have had chest and abdominal surgery by restor-
ing the normal ventilation pattern. ~ Nevertheless, controversy
remains over the efficacy of respiratory rehabilitation in dimin-
ishing the incidence of PPC and over the identification of those
patients who might truly benefit from respiratory rehabilitation,
ie, all patients or only high-risk cases.
This study investigated whether preoperative and postopera-
tive respiratory rehabilitation improves lung function and dimin-
ishes the incidence of PPC after supraumbilical laparotomy, and
whether such benefit is experienced by all patients or only by
high-risk patients.
MATERIALS AND METHODS
A randomized clinical trial considered 115 consecutive pa-
tients older than 15 years of age who had elective supraumbilical
laparotomy in a department of general and digestive surgery.
Supraumbilical laparotomy had been performed in all cases,
regardless of the type of incision employed. All patients gave
informed verbal consent to take part in the study.
Thirty-four patients were excluded from the study, 64.5%
because of surgery-related reasons (need for emergency opera-
tion, extrapulmonary postoperative complications, infraumbili-
cal extension of the laparotomy) and 35.5% as a result of incom-
plete protocols atta-ibutable to patient-related causes (lack of
cooperation).
The 81 patients who could be evaluated (46 women and 35
men with a mean age of 64.1 years [range, 18-84]) were distrib-
uted into two homogeneous groups, a control group (n = 41)
and a respiratory rehabilitation group (n = 40).
Standard balanced anesthesia was used in all cases, consisting
of sodium thiopental, atracurium, fentanyl, and isoflurane. The
doses were varied only according to patient weight and duration
of surgery.
To minimize negative effects on pulmonary function caused
Arch Phys Med RehabU Vol 79, January 1998
6 POSTOPERATIVE RESPIRATORY REHABILITATION, Chumillas
Table 1: Pulmonary Risk Score
Parameters Score
Spirometry*
FVC <50%
FEV1/FVC
65% to 75%
50% to 65%
<50%
Age ->65 yrs
BMI >25%
Abdominal surgery, supraumbilical
Pulmonary history*
Antecedents
Cough and expectoration
Smoker
* Cumulative score: Spirometry, 0-4; pulmonary history, 0-3.
by postoperative pain from the surgical wound, all patients re-
ceived the same postoperative analgesic regimen, chosen for its
negligible repercussion on respiration: 2g magnesium methami-
zole diluted in 100mL physiological saline administered intrave-
nously every 8 hours. Oral dosing was substituted in the follow-
ing days, or on restoration of bowel transit.
Patient Classification
Since up to 80% of all patients who will subsequently have
complications can be identified using clinical history, physical
examination, and spirometry,7 the parameters considered for
evaluating pulmonary risk were age, supraumbilical surgery,
pulmonary antecedents, the presence of pulmonary symptoms,
tobacco smoking, body mass index (BMI) as an objective crite-
rion of obesity ~2 and calculated as body weight (kg) divided by
size (m2), and spirometry. As a function of a score7J3 (table 1),
the patients were distributed into risk groups (low, 0-3; moder-
ate, 4-6; high, ->7) and randomly assigned either to the study
group, which received preoperative and postoperative respira-
tory rehabilitation, or to the control group, which did not receive
respiratory rehabilitation. Nevertheless, most of the patients
(91.4%) belonged to moderate- or low-risk subgroups.
The patients had physical examination, spirometry, arterial
gasometry, and simple chest X-rays using the habitual antero-
posterior and lateral projections. These evaluations were made
preoperatively and after surgery on days 2, 4, and 6, with the
exception of gasometry, which was performed only on post-
surgery days 2 and 4.
The spirometric results were obtained using a portable auto-
matic spirometer," with the patient seated and following the
norms of the Spanish Society for Pathology of the Respiratory
Apparatus. I6 The best of at least three valid spirometric maneu-
vers was selected. Forced vital capacity (FVC) and forced expi-
ratory volume in 1 second (FEV~, measured in milliliters and
as a percentage of the reference value) were calculated, as well
as the ratio FEVI/FVC.
Arterial gases were analyzed after extracting an arterial blood
sample by radial artery puncture. The specimen was immedi-
ately processed in the central laboratory of the hospital with
an IL 1306 gas autoanalyzer, b Arterial oxygen partial pressure
(Pao2), arterial oxygen saturation (Sao2), and arterial carbon
dioxide partial pressure (Paco2) were recorded.
The simple chest X-rays were taken in the Department of
Radiodiagnostics, where a report was issued of the results ob-
tained, with no further clinical data. The radiological alterations
were defined as segmental or subsegmental atelectasis, with
infiltration or consolidation, according to the criteria of the radi-
ologist.
The postoperative clinical pulmonary complications were de-
fined according to clinical (symptoms and physical examina-
tion) plus radiological criteria as bronchitis, atelectasis, and
Arch Phys Med Rehabil Vol 79, January 1998
pneumonia (table 2). When there were only radiological alter-
ations without clinical symptoms or alterations in auscultation,
the complications were considered as subclinical.
1 Other study variables of interest were patient age, sex, and
duration of surgery (shorter or longer than 120min).
1
2 Respiratory Rehabilitation Protocol
3
1 The 40 patients assigned to the study group were subjected
1 to a previously designed respiratory rehabilitation protocol com-
2 prising patient awareness, adequate instruction about the forced
1 expiration technique ~° and cough mechanism, chest expansion
I exercises and diaphragmatic mobilization, maximal inspiration
1 sustained for 3 to 5sec, and early ambulation after surgery.
From 2 to 3 days before the operation until discharge (by day
7 after surgery, on average), the exercises were performed for
10 to 15rain, four times daily. During the first 2 postoperative
days the exercise sessions were more frequent: 10rain every 2
hours. A physiatrist and a physical therapist instructed the pa-
tients on the different exercises and monitored correct exercise
performance on a daily basis.
Statistical Analysis
The analysis of the incidence of PPC according to whether
or not respiratory rehabilitation had been provided was carried
out by the X2 test, with a stratified analysis by risk factors. The
possible association between the degrees of risk and PPC, as
well as the effect of respiratory rehabilitation in the different
risk subgroups, was investigated by stratified analysis and the
X2 test. A multivariate analysis was also performed based on
the nonconditional logistic regression method, comprising those
variables regarded as most relevantJ 5
The effect of respiratory rehabilitation on the decrease in
postoperative lung function was analyzed in terms of the differ-
ences in spirometric and gasometric mean _+ 95% confidence
intervals (95%CI) between the preoperative and postoperative
values recorded in each group, using the Student t test for paired
samples. The Student t test for nonpaired samples was in turn
employed for comparisons between groups. 15
RESULTS
No significant differences were observed in the sample char-
acteristics or in the risk factors of both groups, with the excep-
tion of sex distribution. Likewise, no differences were recorded
in the average duration of surgery, in the types of incision
performed in each group, or in the chest X-ray alterations ob-
served preoperatively.
Postoperative Pulmonary Complications
The global incidence of complications (table 3) in the series
was 13.6%. The three complications recorded in the respiratory
Table 2: Definition of PPC
Bronchitis
Chest X-ray negative
Temperature of <37.5°C
Auscultation: rales
Sputum abundant and clear
Atelectasis
Chest X-ray: collapse, diaphragmatic elevation
Temperature of <38°C
Auscultation: diminished or abolished vesicular murmur
Pneumonia
Chest X-ray: consolidation, pleuresy
Temperature of >38°C (->4 days)
Auscultation: rales
Sputum abundant and purulent
 POSTOPERATIVE RESPIRATORY REHABILITATION, Chumillas
Table 3: Clinical PPC and Radiological Alterations by Groups
Control Rehabilitation Odds
(n - 41) (n = 40) Total Ratio
Pulmonary clinical
complications 8 (19.5%) 3 (7.6%) 11 (13.6%) .33
Radiological
alterations 16 (39%) 6 (15%) 22 (27.5%) .28
rehabilitation group (7.5%) corresponded to two cases of bron-
chitis, and atelectasis in one patient. In turn, the 8 PPC (19.5%)
observed in the control group corresponded to bronchitis (1
case), atelectasis (6 cases), and pneumonia (1 case). Although
the incidence of complications was greater in the controls, there
were no statistically significant intergroup differences (p = . 11 ).
The postoperative X-rays (table 3) revealed alterations in
27.5% of cases, with a higher incidence in the control group (p
= .017). More than 50% of the pathological images, however,
were of no clinical significance. The control group showed sub-
segmental atelectasis in 13 cases and segmental atelectasis in 3
cases (one with consolidation). The rehabilitation group showed
subsegmental atelectasis in 5 cases and segmental atelectasis in
1 patient.
The univariate analysis of several risk factors, in the 81 pa-
tients, found no increased incidence of complications, except
when the duration of surgery exceeded 120min; the incidence
of PPC was 21.4%, versus only 5.1% for surgical times of less
than 120min. Thus, only surgery lasting longer than 120min was
found to be a determinant factor for increased complications
(p = .03). On analyzing PPC by stratifying the control and
rehabilitation groups according to the different risk factors in-
vestigated, however, no significant differences were observed
between the two groups of subjects. The risk of PPC implied
by the duration of surgery was not influenced by having or not
having received respiratory rehabilitation.
The analysis of the risk subgroups found that increased risk
was significantly (p = .044) linked to a greater number of PPC.
On studying the complications in the control group versus the
rehabilitation group stratified by risk degree (table 4), however,
although decreases in PPC of 17% and 15% were observed,
respectively, in the high-risk and moderate-risk rehabilitation
subgroups, the summarizing X2 test showed no significant differ-
ences between the groups.
In the case of the multivariate analysis, we employed a retro-
grade approach based on a saturated model comprising six vari-
ables. PPC was taken as dependent variable, while the indepen-
dent variables were sex, tobacco consumption, pulmonary
antecedents, duration of surgery, and respiratory rehabilitation.
The best explanatory model contained the variables of pulmo-
nary antecedents, duration of surgery, and respiratory rehabilita-
tion. The rest of the variables lacked explanatory value. Thus,
the risk of PPC in patients with antecedent pulmonary pathology
(p = .025) or whose surgery lasted longer than 120min (p =
.036) was significantly greater than the risk in relation to the
remaining variables. On the other hand, preoperative and post-
operative respiratory rehabilitation diminished the risk of devel-
oping PPC; the corresponding odds ratio (OR) was close to
statistical significance (p = .061, 95%CI = .04 to 1.09).
Postoperative Spirometric Alterations
Both groups showed a sudden decrease in FVC and FEV~
from values recorded before surgery, the lowest values being
recorded 48 hours after surgery. This was followed by a gradual
recovery over the next few days, although preoperative values
still had not been reached 6 days after surgery. A large signifi-
cant difference (p = .0000) was established between the preop-
erative and three postoperative FVC and FEV~ determinations,
7
both in the controls and in the respiratory rehabilitation group,
but not in the different determinations between groups. The
P FEV1/FVC ratio underwent no significant postoperative varia-
tions.
.11 To quantify the importance of the postoperative decrease in
FVC and FEVj values, the percentages of the decreases with
.017
respect to their corresponding preoperative values (regarded as
basal) were analyzed. Thus, 48 hours after surgery FVC had
decreased to 55% of its preoperative value, and FEV~ had de-
creased to 51%. These parameters gradually recovered to 76%
and 72%, respectively, by day 6. This postoperative variation
was similar in both groups, with no significant differences.
Postoperative Gasometric Alterations
Diminished Sao2 values (although within the normal range)
and hypoxemia were recorded postoperatively. These decreases
were maximal by day 2, and a gradual increase was observed
over the following days. There were no significant variations
in PacQ. In both the control and respiratory rehabilitation
groups, a statistically significant difference was observed be-
tween the preoperative and two postoperative determinations of
Pao2 and Sao2 (p < .05), although no significant differences
were recorded between the two groups.
Taking the preoperative mean as basal value, we found that
surgery caused a decrease in Pao2 after 48 hours to 87.8%
of the presurgical values. This parameter recovered over the
subsequent days. The decreases observed were similar in both
groups, with no significant differences.
DISCUSSION
Studies on the efficacy of the different forms of pulmonary
physical therapy in preventing PPC are not conclusive, because
variability exists in the rehabilitation techniques employed, the
definitions used, and in the incidence of PPC. 9'f ~.~62f
Studies have reported a high incidence of PPC, based on the
interpretation of chest X-rays and regarding as complications
those radiological alterations lacking clinical significance. In
agreement with Schwieger, t7 we have observed a greater inci-
dence of radiological alterations, half of which tend to improve
spontaneously.~'-18'22 This cannot be attributed to bias on the
part of the radiologist, who in no case was informed of patient
condition.
We consider that the low incidence of PPC in our series
(13.6%) (ie, in the lower range reported in the literature)6-9 may
be due to several reasons: (1) general prophylactic measures
(eg, early ambulation and postoperative analgesia) were routine
in the management of surgical patients; (2) there have been
important technical developments in anesthesia in recent
years23; and (3) most patients (91.4%) were moderate- or low-
risk cases.
The risk factors frequently related to PPC were smoking, the
presence of preoperative or coexistent pulmonary pathology,
obesity, and the duration of surgery.4'24 In our series, multivari-
ate analysis suggests that both surgical times longer than
120min and antecedent puhnonary pathology significantly in-
crease the risk of PPC. Because of sample size limitations,
however, univariate analysis only demonstrated a significant
Table 4: PPC by Risk and Group
Control Rehabilitation
Degree of Risk (PPC/n) (PPC/n) Total (PPC/n) p
High (>7) 2/4 (50%) 1/3 (33.3%) 3/7 (42.9%) 1.0
Moderate (4-6) 5/25 (20%) 1/20 (5%) 6/45 (13.3%) 0.20
Low (0-3) 1/12 (8.3%) 1/17 (5.9%) 2/29 (6,9%) 1.0
Arch Phys Med Rehabil Vol 79, January 1998
8 POSTOPERATIVE RESPIRATORY REHABILITATION, Chumillas
increase in risk in relation to surgical times longer than 120min.
This coincides with the observations of Hall and colleagues, 25
and supports the idea that the development of complications is
to a large degree dependent on the type of surgery performed,
since longer and more complex operations entail greater visceral
manipulation, which in turn causes a greater inhibition of the
diaphragmY
Nevertheless, when PPC were analyzed on patients classified
into risk subgroups, risk was effectively found to be in direct
proportion to the appearance of postoperative complications.
Respiratory Rehabilitation
Although there have been few controlled studies, Celli and
colleagues 16 and Roukema and associates 26 found a statistically
significant, 50% decrease in complications among patients per-
forming breathing exercises or with mechanical aids, ie, incen-
tive spirometer or intermittent positive pressure breathing, and
Morran and associates 2° recorded a significant decrease in the
incidence of postoperative pneumonia in patients who per-
formed breathing exercises. Schwieger et al, ~7 using incentive
spirometer, obtained a 10% decrease in the number of complica-
tions, though without reaching statistical significance. We used
breathing exercises that have been reported to increase dia-
phragm mobility 23~27-29and decrease basal atelectasis. The results
failed to yield significant differences in PPC reduction between
groups. However, the 12% decrease observed in the incidence
of PPC in the rehabilitation group versus the control group, and
the odds ratio close to statistical significance (revealed by the
multivariate analysis), suggest the existence of a protective and
beneficial effect on the part of respiratory rehabilitation in rela-
tion to the appearance of PPC.
As has also been reported by other authors, ~6't7 respiratory
rehabilitation was found to significantly diminish postoperative
radiological alterations.
A deduction common to all of the above-mentioned studies
is that some form of rehabilitation seems better than none, even
though the complete elimination of PPC may not prove possible.
According to Celli, 23 all of the respiratory rehabilitation meth-
ods appear to be effective, although no general agreement exists
over which is best or what the optimal treatment schedule may
be. The method of choice is therefore dependent on the available
resources.
On investigating the effect of respiratory rehabilitation in the
different risk subgroups, however, a nonsignificant 15% to 17%
decrease was observed in the incidence of complications among
the high- and moderate-risk subgroups. The PPC percentages
were similar in the low-risk subgroups. These observations
agree those of Zibrak and colleagues, 8 who recommended
avoiding the indiscriminate use of respiratory therapy, reserving
it for the high- and moderate-risk groups, who stand to derive
most benefit. As a result, related and unwarranted costs could
be curbed.
Functional Alterations
Altered pulmonary volumes and arterial gases caused by up-
per abdominal surgery have been confirmed by several au-
thors) -63° Parfrey et al 3° and Latimer and colleagues 6 reported
that FVC decreased, respectively, to 27% and 35% of preopera-
tive values in the first 24 hours. According to other authors, 3'3~
postoperative hypoxemia is maximal on the day of the opera-
tion. In our study, the first postoperative recording was made
after 48 hours; consequently, the decreases in pulmonary vol-
umes and P a Q in our series were less.
Most studies ~7'19'~1'32that have evaluated the ability of respira-
tory rehabilitation to minimize postoperative changes in pulmo-
nary volumes, including our own, have reported no relevant
Arch Phys Med Rehabil Vol 79, January 1998
differences between controls and treated patients, or between
groups subjected to different therapeutic regimens.
As regards the effect of respiratory rehabilitation on postoper-
ative arterial gas alterations, several studies 17'19'2°'21'32failed to
find differences in arterial gas variations between treated and
nontreated groups. These observations agree with our own re-
sults. Only isolated studies such as that by Bartlett et al, 33 based
on incentive spirometer, have reported slight improvement in
oxygenation among treated patients.
We are of the opinion that the lack of significant intergroup
differences may be explained by the difficulty involved in re-
cruiting high-risk patients 7 while preserving sample homogene-
ity, the possibility that pulmonary function testing may not be
sufficiently sensitive to identify the functional changes induced
by rehabilitation, 5'3~ and the low incidence of PPC in our series.
CONCLUSIONS
Surgical times in excess of 120rain, a history of pulmonary
pathology, and belonging to moderate- or high-risk subgroups
are all factors that increase the possibility of developing PPC.
Surgery induces significant decreases in pulmonary volumes
and arterial gas levels that are not minimized by respiratory
rehabilitation. Nevertheless, respiratory rehabilitation allows a
decrease in the postoperative radiological alterations and exerts
a protective effect against PPC. Finally, respiratory rehabilita-
tion is more effective in moderate- and high-risk cases and
should thus be recommended in such patients.
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Arch Phys Med Rehabil Vol 79, January 1998