International Journal of Cardiovascular Sciences.

2020; xx(x):xxx-xxx
1

ORIGINAL ARTICLE

Effects of Inspiratory Muscle Training Using an Electronic Device on Patients

Undergoing Cardiac Surgery: A Randomized Controlled Trial
João Vyctor Silva Fortes,1 Mayara Gabrielle Barbosa Borges,1 Maria Jhany da Silva Marques,1 Rafaella Lima
Oliveira,1 Liana Rodrigues da Rocha,1 Érica Miranda de Castro,1 Mateus Souza Esquivel,2 Daniel Lago Borges1
Cardiology Intensive Care Unit, Hospital Universitário da Universidade Federal do Maranhão,1 São Luís, MA - Brazil.
Research Group in Cardiovascular Physiotherapy,2 Salvador, BA - Brazil.

Abstract

Background: Cardiac surgery causes pathophysiological changes that favor the occurrence of pulmonary and
functional complications.
Objective: To investigate the effects of inspiratory muscle training (IMT) with an electronic device on patients
undergoing cardiac surgery.
Methods: A randomized controlled trial was conducted with 30 adult patients undergoing elective cardiac surgery.
A control group (CG) received conventional physical therapy care, and an intervention group (IG) received IMT
using the POWERbreathe K5® electronic device. Two daily sessions of physical therapy were performed at the
intensive care unit and one daily session at the ward until the sixth postoperative day. The following variables were
measured preoperatively and on the sixth postoperative day, in both groups: inspiratory muscle strength, dynamic
inspiratory muscle strength, and peak inspiratory flow. Data distribution was evaluated by the Shapiro-Wilk test.
Analysis of variance was used, and the results were considered statistically significant when p < 0.05.
Results: Maximal inspiratory pressure (71.7 ± 17.1 cmH2O vs 63.3 ± 21.3 cmH2O; p = 0.11], S-index (52.61 ± 18.61 vs
51.08 ± 20.71), and peak inspiratory flow [(2.94 ± 1.09 vs 2.79 ± 1.26)] were maintained in the IG but had a significant
reduction in the CG.
Conclusion: IMT performed with an electronic device was effective at maintaining inspiratory muscle strength,
dynamic inspiratory muscle strength, and peak inspiratory flow when compared to conventional physical therapy.
(Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx)
Keywords: Respiratory Tract Diseases/complications; Cardiac Surgery/complications; Breathing Exercises; Muscle
Strength; Physiotherapy; Rehabilitation.

Introduction Respiratory muscle training has received considerable

attention in the field of cardiopulmonary physical
Cardiopulmonary physical therapy is widely used in therapy because of its direct benefits for respiratory
prevention and treatment of complications after cardiac
muscles.3 Within respiratory muscle training, inspiratory
surgery. 1 Some strategies can be used to minimize
muscle training (IMT) has long been administered to
complications, including physical therapy, continuous
some patients, including those with chronic obstructive
positive pressure, intermittent positive pressure
breathing (IPPB), bi-level positive airway pressure pulmonary disease, and its reported benefits include
(BiPAP), and respiratory stimulants, all of which have increased respiratory muscle strength, improved
been found to be safe, easy to administer, and very symptoms of dyspnea, and greater ability to perform
effective for patient recovery in the postoperative period.2 physical exercise.4

Mailing Address: João Vyctor Silva Fortes

Cardiology Intensive Care Unit, Hospital Universitário da Universidade Federal do Maranhão
Rua Barão de Itapary, 227. Postal code: 65020-070, Centro, São Luís, MA - Brazil.
E-mail: [email protected]
DOI: https://doi.org/10.36660/ijcs.20190093 Manuscript received on May 26, 2019; reviewed on May 14, 2020; accepted on May 16, 2020.
Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx Fortes et al.
Original Article Inspiratory Muscle Training After Cardiac Surgery 2

IMT has also been used in the treatment of chronic elective cardiac surgery Coronary artery bypass
heart disease and the control of diastolic and systolic grafting (CABG), valve replacement, or CABG + valve
blood pressure.5 Stroke patients who have undergone replacement) from June 2016 to February 2017 and who
IMT have increased ability to perform activities of were admitted to the Cardiology Intensive Care Unit
daily living, improved walking ability, and increased (CICU) at Hospital Universitário da Universidade Federal
respiratory muscle strength.6 do Maranhão (HUUFMA) in this period.
Some studies have demonstrated that the use of IMT Patients with preexisting pulmonary or neurological
in the preoperative period of cardiac surgery increases diseases described on medical records or who did not
inspiratory muscle strength, decreases the incidence of agree to participate in the study were not included.
pulmonary complications, and reduces length of hospital Those who died in the preoperative period or who
stay.7,8 IMT has been found to improve tidal volume developed postoperative pulmonary or neurological
and vital capacity and reduce the length of stay in the complications that prevented the evaluations, and those
cardiology department following cardiac surgery.1 The requiring prolonged mechanical ventilation (> 24 hours)
beneficial effects of IMT have also been observed in cases or noninvasive mechanical ventilation for more than 4
of diaphragm paralysis after cardiac surgery.9 hours per day were excluded.
At present, some electronic devices are commonly
used to perform IMT, such as Threshold®, a flow- Measurements
independent linear load device,3 and POWERbreathe®,
The patients were informed about the study in the
which can be used for assessment of respiratory training
preoperative period. Those who agreed to participate
and pulmonary function. 6,10 The POWERbreathe®
and met the inclusion criteria signed an informed consent
devices differ from others because they are electronic
form. The enrolled patients completed an evaluation that
devices that allow adjusting the load proportionally to
included the following items:
the inspiratory flow, i.e., the higher the flow generated by
the individual, the greater the resistance, and when the Identification: included demographic data (name,
flow decreases, the resistance is reduced. This variation sex, place of birth, occupation), anthropometric data
according to flow is important as it provides greater (weight, height, body mass index, waist-hip ratio), clinical
comfort to the patient during training.11,12 diagnosis, and personal medical history.

Additionally, electronic devices provide the possibility Manovacuometry: a digital respiratory pressure
of starting training at lower loads, for example 3 cmH2O, meter (MVD300, Globalmed, Porto Alegre, Brazil) was
which is of utmost importance, especially in patients with used to determine respiratory muscle strength based on
very low maximal inspiratory pressure (MIP) values.13 MIP, according to recommendations of the American
However, no studies to date have evaluated IMT using an Thoracic Society and the European Respiratory Society
electronic device in patients undergoing cardiac surgery. for evaluation of the respiratory function.14

Therefore, the objective of this study was to investigate Mortality risk: included InsCor, a risk score used
the effects of IMT on respiratory muscle strength, dynamic to predict mortality in patients undergoing heart
inspiratory muscle strength, and peak inspiratory flow surgery by analyzing several variables, including
(PIF) using an electronic device in patients undergoing age (> 70 years); sex (female); associated surgery
cardiac surgery. (CABG + valve replacement); recent infarction
(< 90 days); reoperation; aortic valve repair; tricuspid
valve repair; creatinine (> 2 mg/dL); ejection fraction
Methods
(< 30%); and preoperative events such as use of intra-
This randomized clinical trial was performed in the aortic balloons, cardiogenic shock, tachycardia or
Department of Cardiac Surgery at the XXXXXXXXXXXXX ventricular fibrillation, orotracheal intubation, acute
at the XXXXXXXXXXXX. renal failure, use of inotropic drugs, and cardiac
massage. Each of these variables had specific scores,
which were summed to classify the patient into one
Patients
of three categories: low risk (0–3 points), moderate
The study population consisted of a convenience risk (4–7 points), or high risk (> 8 points), as defined
sample of 30 consecutive adult patients who underwent by Mejía et al.15
 Fortes et al. Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx
3 Inspiratory Muscle Training After Cardiac Surgery Original Article

Inspiratory muscle dynamics: was measured using the underwent 30 respiratory cycles using a MIP load of
POWERbreathe K5® electronic device (POWERbreathe 30% on the first postoperative day.18 A new evaluation
International Ltd., Warwickshire, England). Dynamic was performed to redefine the MIP load on the third
inspiratory muscle strength (S-index) and PIF were postoperative day.19
assessed according to Lee et al.6 and Minahan et al.16 The conventional physical therapy protocol for both
groups was provided as recommended by Mendes and
Protocols Borghi-Silva,20 with the following instructions: adequate
posture, deep inspiration, protection of the chest, stimulation
Patients were randomized by a simple drawing, after
of the return of functional activities, encouragement to
CICU admission, and divided into a control group (CG),
cough, pulmonary re-expansion techniques, diaphragmatic
which received conventional physical therapy care,
breathing, timed breathing exercises, active range-of-motion
and an intervention group (IG), which received IMT in
exercises involving the limbs, active-assistive or active
addition to conventional care.
range-of-motion exercises (depending on each patient’s
Patients initiated IMT 6 hours after extubation, usually condition) involving the elbows, shoulders, hips, and knees,
on the first postoperative day. In the CICU, the patients early removal from the bed and from sedation, reduced
remained in semi-Fowler's position at 45º17 or, if possible, ambulation (according to each patient's condition), and
were placed on a chair with their feet flat on the floor and oxygen therapy, when necessary.
their back against the back of the chair for support (Figure Inspiratory muscle strength, inspiratory muscle
1). The seated position was also used in patients who dynamics, and PIF were reassessed on the sixth
were hospitalized but not in the CICU.5 In both situations, postoperative day, and the data were compared. All
patients were instructed to exhale calmly, followed by a patients received the same analgesia protocol with
maximal forced inspiration to total lung capacity using a intravenous morphine (2–5 mg every 4 hours).
mouthpiece and a nasal clip as an aid to prevent air leaks.17 Interventions were performed by junior and
IMT was performed in two daily sessions during senior physiotherapists. However, baseline and
the patients' stay in the CICU. Other hospitalized outcome assessments were conducted by a blinded
patients performed only one daily session. The patients senior physiotherapist.

Figure 1 – Participant in semi-Fowler’s position undergoing an IMT session on the first postoperative day.
Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx Fortes et al.
Original Article Inspiratory Muscle Training After Cardiac Surgery 4

Statistical Analysis Results

The collected data were analyzed using Stata/SE
software, version 12.1 (Statacorp, College Station, Texas, The 30 patients included in the study had a mean age
USA). The Shapiro-Wilk test was used to assess the of 59.2 ± 13.1 years and were divided into two groups,
normality of the groups. Quantitative variables with as shown in Figure 1. Other demographic and clinical
normal distribution are presented as mean and standard
variables are detailed in Table 1. None of the analyzed
deviation, while continuous variables with non-normal
distribution are described as median and interquartile variables differed significantly between the two
range. Their differences were determined using paired groups, indicating that the sample was homogeneous.
and unpaired Student's t-test and Mann-Whitney test. There were no significant differences in surgical data,
Categorical variables are presented as absolute numbers
mechanical ventilation duration, length of CICU stay,
and percentages, and their association was assessed
using Fisher's exact test. The results were considered and length of hospital stay between the two groups
statistically significant when p < 0.05. (Table 2).

Assessed for eligibility (n = 37)

Excluded (n = 7)
• Death (n = 3)
• Mechanical ventilation > 24 horas (n = 2)
• Impossibility to reassess (n = 2)

Randomized (n = 30)

Participants in Control Group Participants in Intervention Group

• Conventional physiotherapy protocol (n = 15) • Inspiratory muscle training protocol (n = 15)

Analyzed (n=15) Analyzed (n=15)

Figure 2 – Study flowchart.

 Fortes et al. Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx
5 Inspiratory Muscle Training After Cardiac Surgery Original Article

Table 1 - Demographic and clinical data of patients undergoing cardiac surgery.

Variables Control (n = 15) Intervention (n = 15) p

Gender 0.99a

Male 12 11

Female 3 4

Age (years) 59.7 ± 13.1 61.5 ± 12.3 0.70b

BMI (kg/m2) 25.0 ± 3.4 25.7 ± 3.0 0.54b

WHR 0.98 ± 0.06 0.98 ± 0.06 0.72b

Comorbidities

Hypertension 10 11 0.99a

Smoking 4 9 0.14a

Diabetes mellitus 9 6 0.47a

Dyslipidemia 4 4 0.99a

AMI 3 7 0.15a

Chronic renal failure 2 1 0.99a

Ejection fraction
Reduced (< 40%) 2 2
0.99a
Mid-range (40-49%) 2 1
Preserved (> 50%) 11 12

InsCor
Low risk 12 9
0.21a
Medium risk 2 6
High risk 1 0
Surgery
CABG 9 8
0.99a
Valve 5 6
CABG + valve 1 1

BMI: body mass index; WHR: waist-hip ratio; AMI: acute myocardial infarction; InsCor: mortality risk in cardiac surgery; CABG: coronary artery
bypass grafting. aFisher’s exact test. bUnpaired Student’s t-test.

Table 2 - Surgical data, mechanical ventilation duration, and length of CICU and hospital stay, per group, in patients
undergoing cardiac surgery

Variables Control (n = 15) Intervention (n = 15) p

Pump time (minutes) 96 (69.5; 111.5) 110 (90.5; 119) 0.30a

Cross-clamp time (minutes) 68 (51; 87.5) 87 (76; 99.5) 0.11a

Surgery time (minutes) 202 (184.5; 255) 210 (201.5; 269) 0.33a

MV duration (hours) 10.5 ± 7.1 9.5 ± 5.9 0.66b

CICU stay (days) 4.0 ± 1.9 3.8 ± 1.3 0.73b

Hospital stay (days) 13.1 ± 5.8 13.4 ± 7.4 0.89b

MV: mechanical ventilation; CICU: cardiology intensive care unit. aMann-Whitney test. bUnpaired Student’s t-test.
Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx Fortes et al.
Original Article Inspiratory Muscle Training After Cardiac Surgery 6

Manovacuometry Studies show that patients undergoing cardiac surgery

have a high risk of postoperative pulmonary complications
MIP differed significantly only in the CG (p < 0.007)
such as pneumonia, atelectasis, bronchospasm, prolonged
but remained unchanged in the IG ​​(p < 0.11) when mechanical ventilation, and acute respiratory failure.21,22
comparing preoperative and sixth postoperative day The incidence of these complications may reach up to
assessments (Table 3). 87%, as found by Ortiz et al.23
Respiratory muscle strength is compromised after
cardiac surgery and may take up to 6 weeks to reverse.24,25
S-index Evaluation
Some factors, including anesthesia and surgery, have
The S-index was significantly decreased in the CG (p been associated with a decrease in this parameter.26 IMT
< 0.001) but remained unchanged in the IG; there was no has been reported to serve as an option for minimizing
significant intergroup difference in this variable. PIF was these losses, 8,27,28,29 and our study corroborated this
finding. Patients who received IMT had similar MIP
significantly decreased only in the CG (Table 4).
values in the preoperative and postoperative periods of
cardiac surgery.8,28,29
Discussion Therefore, IMT may be an important strategy for
minimizing respiratory muscle weakness due to cardiac
The present study determined the effect of IMT using
surgery.28 Hulzelbos et al.30 reported that maintaining or
an electronic device on patients undergoing cardiac increasing respiratory muscle strength is important to
surgery. Respiratory muscle strength and inspiratory reduce the effects of pulmonary complications and has
muscle dynamics were analyzed. even decreased the length of hospital stay.

Table 3 - Comparison of maximal inspiratory pressure between study groups

Control (n =15) Intervention (n = 15) p

MIP (cmH2O)
Preoperative 80.2 ± 33.7 71.7 ± 17.1
0.35
POD 6 56.5 ± 20.4 63.3 ± 21.3
0.53
p 0.007 0.11

MIP: maximal inspiratory pressure; POD: postoperative day. Data showed as mean ± standard deviation. Paired Student’s t-test (intragroup) and
unpaired Student’s t-test (intergroup).

Table 4 - Comparison of inspiratory muscle dynamics between study groups

Control (n = 15) Intervention (n = 15) p

S-index (cmH2O)
Preoperative 50.71 ± 24.34 52.61 ± 18.61
0.95
POD 6 34.51 ± 16.62 51.08 ± 20.71
0.04
p < 0.0001 0.79

PIF (L/s)
Preoperative 2.81 ± 1.40 2.94 ± 1.09
0.96
POD 6 1.86 ± 1.00 2.79 ± 1.26
0.03
p < 0.0001 0.69

POD: postoperative day; PIF: peak inspiratory flow. Data showed as mean ± standard deviation. Paired Student’s t-test (intragroup) and unpaired
Student’s t-test (intergroup).
 Fortes et al. Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx
7 Inspiratory Muscle Training After Cardiac Surgery Original Article

Cordeiro et al.28 evaluated 50 patients divided into two were lower in the postoperative period. This effect may
groups. One group underwent IMT using the Threshold® be due to IMT because clinical and surgical variables
device twice a day, with 3 sets of 10 repetitions, and the were homogeneous in the study groups.
other group received only conventional ICU care, both PIF measure has been associated with respiratory
until hospital discharge. The authors observed that the muscle strength.34 Nemopuceno et al.,17 when analyzing
Threshold® group maintained its MIP values when 10 individuals who underwent IMT twice a day for
compared to the other group. This is consistent with the a period of 4 weeks after prolonged hospitalization,
results of this study, in which training lasted only until observed that these patients had increased PIF at the
the sixth day. end of training. Weiner et al.35 found that patients who
The literature has emphasized the importance of underwent IMT presented a significant increase in MIP
performing IMT in the preoperative period. Some and PIF. These authors observed that inspiratory muscle
systematic reviews and meta-analyses show that when strength played an essential role in the generation of PIF.
started in this period, IMT helps maintaining MIP, However, no studies to date have provided reference
reduces the risk of postoperative complications, and ranges for this parameter.
decreases the length of hospital stay.8,22 In this study,
we investigated the effects of IMT only on inspiratory Study Limitations
muscle strength.
To our knowledge, this is the first study to investigate
IMT can be performed with linear pressure resistors
the effects of IMT on cardiac surgery patients using a
such as Threshold®, which has been on the market for
new electronic device until the 6th postoperative day.
a long time and has already shown its effectiveness for
However, there are limitations regarding the small
gaining respiratory muscle strength. Recently, electronic
number of patients and the number of training sessions
load-adjusting devices such as the POWERbreathe
(only six). Most studies with IMT after cardiac surgery
K-series® (K1-K5) have been used. These devices adjust
perform training until hospital discharge. Another
to the load imposed on respiratory muscles in proportion
limitation of the present study was the non-reevaluation
to the flow; the higher the flow, the greater the resistance,
of inspiratory muscle strength (MIP and S-index) and PIF
so the flow decreases the resistance, also providing
on the day of discharge, so that there was a comparison
greater comfort to the patient.31,32 with the sixth postoperative day values. For these
In another study, Charususin et al. 33 used IMT reasons, further randomized controlled trials with larger
with POWERbreathe® associated with pulmonary samples are needed to compare their results with those
rehabilitation in patients with chronic obstructive of the present study.
pulmonary disease who had respiratory muscle
weakness. At the end of the study, they observed Conclusion
increased endurance and improved dyspnea sensation
in the patients. IMT performed with an electronic device was found to
The S-index can be measured using the POWERbreathe be effective at maintaining inspiratory muscle strength,
K-series® and is used to assess dynamic inspiratory dynamic inspiratory muscle strength, and PIF when
muscle strength.29 While MIP is obtained by maximal compared to conventional physical therapy.
static inspiratory effort, the S-index is measured during a
dynamic unobstructed inspiratory maneuver. Moreover, Acknowlegments
when MIP cannot be used to measure inspiratory muscle
The authors are thankful to physiotherapists of the
strength, the S-index appears to be a reliable alternative
Cardiology Intensive Care Unit and Ward of Hospital
assessment.11 However, no studies to date have provided
Universitário – Campus Presidente Dutra at the
reference ranges for this variable. Minahan et al. 11,29
Universidade Federal do Maranhão.
reported that S-index values could not be compared to
MIP values obtained using respiratory pressure meters.
Author Contributions
In the present study, the group that received IMT
maintained their baseline S-index and PIF in the Conception and design of the research: Fortes JVS.
postoperative period; in the control group, these values Acquisition of data: Fortes JVS, Borges MGB, Marques
Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx Fortes et al.
Original Article Inspiratory Muscle Training After Cardiac Surgery 8

MJS, Oliveira RL, Rodrigues LR, Castro EM. Analysis Study Association
and interpretation of the data: Borges MGB, Borges DL. This study is part of the conclusion work of a
Statistical analysis: Borges DL. Writing of the manuscript: multiprofessional residency in health by the authors: João
Fortes JVS. Critical revision of the manuscript for Vyctor Silva Fortes, Mayara Gabrielle Barbosa Borges,
intellectual content: Esquivel MS, Borges DL. Maria Jhany da Silva Marques, Rafaella Lima Oliveira,
Liana da Rocha Rodrigues, Érica Miranda de Castro,
Potential Conflict of Interest Mateus Souza Esquivel, Daniel Lago Borges.
No potential conflict of interest relevant to this article
was reported. Ethics Approval and Consent to Participate
  The study was approved by the Brazilian Registry of
Sources of Funding Clinical Trials (REBEC) (identification no. RBR-8SWGC3)
There were no external funding sources for this study. and by the Research Ethics Committee at our institution
(Consolidated Opinion no. 1.573.419), as recommended
 
by Brazilian National Board of Health (CNS) Resolution
no. 466/12.

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