C A R D I A C R E H A B I L I TAT I O N

Deep Breathing Exercises Performed

2 Months Following Cardiac Surgery
A RANDOMIZED CONTROLLED TRIAL

Elisabeth Westerdahl, PhD; Charlotte Urell, PhD; Marcus Jonsson, MSc; Ing-Liss Bryngelsson, MSc; Hans
Hedenström, PhD; Margareta Emtner, PhD

■ PURPOSE: Postoperative breathing exercises are recommended to cardiac K E Y W O R D S

surgery patients. Instructions concerning how long patients should
continue exercises after discharge vary, and the significance of cardiac surgery
treatment needs to be determined. Our aim was to assess the effects of
deep breathing exercises
home-based deep breathing exercises performed with a positive
expiratory pressure device for 2 months following cardiac surgery. positive expiratory pressure device
■ METHODS: The study design was a prospective, single-blinded, parallel-
group, randomized trial. Patients performing breathing exercises
2 months after cardiac surgery (n = 159) were compared with a Author Affiliations: School of Health and
control group (n = 154) performing no breathing exercises after Medical Sciences, Örebro University,
Örebro, Sweden (Dr Westerdahl);
discharge. The intervention consisted of 30 slow deep breaths
Departments of Physiotherapy
performed with a positive expiratory pressure device (10-15 cm H2O), (Dr Westerdahl and Mr Jonsson),
5 times a day, during the first 2 months after surgery. The outcomes Cardiothoracic Surgery (Dr Westerdahl
were lung function measurements, oxygen saturation, thoracic and Mr Jonsson), and Occupational and
excursion mobility, subjective perception of breathing and pain, Environmental Medicine (Ms
patient-perceived quality of recovery (40-Item Quality of Recovery Bryngelsson), Örebro University Hospital,
score), health-related quality of life (36-Item Short Form Health Örebro, Sweden; and Physiotherapy,
Survey), and self-reported respiratory tract infection/pneumonia and Department of Neuroscience (Dr Urell
antibiotic treatment. and Dr Emtner), and Respiratory
Medicine and Allergology (Dr Emtner)
■ RESULTS: Two months postoperatively, the patients had significantly and Clinical Physiology (Dr Hedenström),
reduced lung function, with a mean decrease in forced expiratory vol- Department of Medical Sciences, Uppsala
ume in 1 second to 93 ± 12% (P < .001) of preoperative values. University, Uppsala, Sweden.
Oxygenation had returned to preoperative values, and 5 of 8 aspects
The authors declare no conflicts of interest.
in the 36-Item Short Form Health Survey were improved compared
with preoperative values (P < .01). There were no significant differ- Correspondence: Elisabeth Westerdahl,
ences between the groups in any of the measured outcomes. RPT, PhD, Örebro University Hospital,
Centre for Health Care Sciences, Box
■ CONCLUSION: No significant differences in lung function, subjective per- 1324, SE-701 85 Örebro, Sweden
ceptions, or quality of life were found between patients performing (elisabeth.westerdahl@orebroll.se).
home-based deep breathing exercises and control patients 2 months
after cardiac surgery. DOI: 10.1097/HCR.0000000000000020

Throughout the world, physical and respiratory thera- tasis and to improve lung function and gas exchange
pies are prescribed after cardiac surgery to reduce or in the early postoperative period.1-4 Deep breathing
prevent postoperative pulmonary complications. with positive expiratory pressure (PEP) is a frequently
Various breathing exercises are used to reduce atelec- used technique for the prophylaxis and treatment of

34 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34;34-42

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JCRP-D-13-00025.indd 34 12/14/13 7:28 PM

 respiratory complications in postsurgical patients in
Sweden.5 Patients are advised to perform these exer-
cises hourly during the initial postoperative days. We
have previously reported positive effects of deep
breathing exercises with PEP on atelectasis, lung vol-
umes, and oxygenation during the hospital stay after
coronary artery bypass grafting.1,6,7 However, instruc-
tions concerning how long patients should continue
the exercises after discharge vary notably in clinical
practice.5 Lung function is impaired for several
months after surgery, but only limited data8 have been
found regarding the effects of home-based breathing
exercises after discharge from hospital following car-
diac surgery.
The aim of this study was to evaluate the effective-
ness of home-based deep breathing exercises per-
formed with a PEP device during the first 2 months
after cardiac surgery. Lung function, oxygenation,
subjective perceptions of breathing, and quality of
recovery were assessed and compared between a
breathing exercise group and a control group per-
forming no breathing exercises. Our hypothesis was
that deep breathing exercises performed during the
first 2 months after cardiac surgery would decrease
pulmonary impairment and improve patient-perceived
quality of recovery and quality of life.
METHODS
The study design was a 2-center, randomized, con-
trolled, single-blind, parallel-group trial. Eligible
patients were adults (aged 18 years or older) undergo-
ing cardiac surgery at Uppsala University Hospital (n
= 204) or Örebro University Hospital (n = 203) in
Sweden between September 2007 and March 2011.
Patients who had an emergency operation, previous
cardiac or lung surgery, kidney failure requiring dialy-
sis, or were unable to communicate in Swedish were
not included.
A total of 407 patients were assessed for eligibility
preoperatively. Of them, 19 patients declined partici-
pation and 31 did not meet the inclusion criteria for
randomization on the fourth to fifth postoperative day
(Figure 1). The exclusion criteria for randomization in
the study were intubation time more than 24 hours;
severe hemodynamic, pulmonary, or neurological
complications; requirement for postoperative dialysis;
sternum-related infections; sternum instability; mental
health disorders; and any other complications that
could affect the patient opportunity to participate in
the study (ie, to perform deep breathing exercises and
spirometry examination). Exclusion from the study
was determined by the study manager (a physical
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JCRP-D-13-00025.indd 35
therapist) at each hospital in consultation with the
cardiothoracic surgeon or cardiothoracic anesthesiolo-
gist. Reoperation in immediate connection with the
operation (within 4-5 hours), intra-aortic balloon
pump, pericardial or pleural drainage treatment, or
pneumothorax during the first 2 postoperative days
after surgery did not disqualify the patient from par-
ticipation in the study, provided that they had recov-
ered by the fourth to fifth postoperative day. Informed
written consent was obtained from each patient, and
the Regional Ethical Review Board in Uppsala,
Sweden, approved the study (2007/160). The trial was
registered at ClinicalTrials.gov (NCT01282671; URL:
www.clinicaltrials.gov).
Surgical and Postoperative Treatment
The day before surgery, or the week before if oper-
ated on a Monday, patients were enrolled in the study
and baseline measurements were performed. Patients
were scheduled to undergo coronary artery bypass
grafting with saphenous vein grafts and/or internal
mammary artery graft, valve surgery, or combinations
of coronary artery bypass grafting and valve surgery.
All patients received general anesthesia, and the surgi-
cal approach was through a median sternotomy.
Coronary artery bypass grafting was performed with
saphenous vein grafts, and in most cases, the left
internal mammary artery graft was used. During anes-
thesia and following surgery, all patients inspired
oxygen with a concentration of 40% to 80%. The
pericardium, the mediastinum, and occasionally 1 or
both pleura were drained, usually less than 24 hours
after surgery. Postoperatively, patients were artificially
ventilated with a positive end-expiratory pressure of 5
to 10 cm H2O. Patients were given analgesics accord-
ing to standard routines and recommendations to use
1-g paracetamol, 4 times daily, for as long as needed
once at home.
All patients received chest physical therapy once or
twice daily during the first 4 postoperative days. The
patients were mobilized as early as possible by the
nursing staff; they were sitting out of bed and/or
standing on the first postoperative day, walking
around the room or for a short distance in the corridor
on the second day, and walking a longer distance in
the corridor on the third day.9 Postoperatively, all
patients performed hourly breathing exercises accord-
ing to ordinary routines from the first postoperative
day until discharge.1,5 Demographic and descriptive
data were collected from medical records.
Intervention
For allocation of the eligible patients, a computer-
generated randomization list stratified for the 2 hospitals
Deep Breathing Exercises / 35
12/14/13 7:28 PM
 Assessed for eligibility (N = 407)

Enrollment Not meeting inclusion criteria or

excluded after surgery (n = 50)
♦ Declined to participate (n = 19)
♦ Could not perform spirometry (n = 4)
♦ Inoperable patient (n = 2)
♦ Intubation/ICU care >72 h (n = 14)
♦ Neurological symptoms (n = 5)
♦ Sternal instability (n = 1)
♦ Mortality (n = 4)
♦ Missing data (n = 1)

Randomized (n = 357)

Allocation
Allocated to breathing group Allocated to control group

(n = 180) (n = 177)

Followup
Lost to followup (reasons See Table 1) Lost to followup (reasons see Table 1)

(n = 21) (n = 23)

Analysis
Analyzed Analyzed

(n = 159) (n = 154)

Figure 1. Study flowchart of the patients in the study. ICU indicates intensive care unit.

was created by a statistician in the form of a Microsoft
Excel file containing identity numbers and group
assignments. This list was administered by an inde-
pendent secretary, who printed notes showing the
group assignment and put them in ordered, sealed,
nontransparent envelopes. On the fourth or fifth post-
operative day, patients were randomly assigned to
perform home-based deep breathing exercises for
2 months following surgery (breathing group, n = 180)
or to perform no breathing exercises after discharge
(control group, n = 177). The breathing group was
instructed to perform 30 deep breaths 5 times a day
during these 2 months. The exercises included three
sets of 10 deep breaths with a 30- to 60-second pause
between each set, all performed in a sitting position. A
PEP device (RIUM breathing exerciser; Rium Medical
AB, Åkersberga, Sweden) (Figure 2) was used to create
a PEP of 10 to 15 cm H2O. Patients were instructed to
perform slow maximal inspirations followed by a 2-sec-
ond inspiratory hold and a slightly activated expiration
ending approximately above functional residual capac-
ity to minimize airway closure and alveolar collapse.
Patient management was otherwise similar between the
groups in terms of assessment, instructions, and mobil-
ity. All patients were contacted at home by telephone
1 month postoperatively, and the breathing group was
also phoned 10 days postoperatively for coaching of
the breathing exercises. Patients in the breathing group

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JCRP-D-13-00025.indd 36 12/14/13 7:28 PM


Figure 2. Breathing exerciser.
documented compliance with treatment in an exercise
diary. Physical therapists at each referring hospital were
contacted by telephone and informed about the study,
and written information was also placed in the patient
medical records.
Measurements
All measurements were assessed preoperatively and
2 months after surgery.
Lung function measurements
Lung function measurements were performed by
experienced biomedical scientists, blinded to the
patient treatment allocation. A Jaeger MasterScreen
PFT/Bodybox (Intramedic AB, Bålsta, Sweden) was
used at both hospitals. The measurements were per-
formed according to the recommendations of the
American Thoracic Society and the European
Respiratory Society.10,11 Slow vital capacity, forced
vital capacity, forced expiratory volume in 1 second
(FEV1), inspiratory capacity, functional residual
capacity, and total lung capacity were assessed.
Predicted values were related to age, gender, and
height.12,13 Saturation of peripheral oxygen was
measured using a pulse oximeter device (Rad-5v;
Masimo, Irvine, CA).
Thoracic excursion
Thoracic excursions were measured using a tape
(marked in millimeters) around the circumference of
the chest at the level of the xiphoid process, to give a
measurement of chest expansion or mobility. Patients
were asked to stand with their hands placed on their
head and given the instructions “breathe in maximally
and make yourself as big as possible” and “breathe
out maximally and make yourself as small as possi-
ble.” The difference between maximal inspiration and
expiration was calculated.14
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JCRP-D-13-00025.indd 37
Subjective perceptions of breathing exercises
and pain
The patients in the breathing group were asked to
score compliance with, subjective benefit from, and/
or discomfort associated with the breathing exercises
on an arbitrary scale from 0 (not at all) to 3 (very
much). All patients were asked to assess sternotomy
wound pain at rest, while taking a deep breath, and
while coughing on a Numerical Rating Scale from 0
(no pain) to 10 (worst imaginable pain) 2 months after
surgery. Finally, the patients were asked about self-
reported symptoms of respiratory tract infections/
pneumonia and antibiotic treatments during the study
period.
Patient-perceived quality of recovery
Patient-perceived quality of recovery was assessed at
the fourth postoperative day and 2 months after sur-
gery, using a Swedish version15 of a validated 40-Item
Quality of Recovery (QOR-40) score16,17 designed to
measure health status after surgery and anesthesia.
The QOR-40 measures 5 dimensions: physical com-
fort, emotional state, physical independence, psycho-
logical independence, and pain. The items are rated
on a 5-point Likert scale (for positive items, 1 = “none
of the time” to 5 = “all of the time”; for negative
items, the scoring is reversed). The lowest possible
score is 40 (extremely poor quality of recovery), and
the highest possible score is 200 (excellent quality of
recovery).16
Health-related quality of life
Health-related quality of life (HRQOL) was assessed
using a Swedish version of the 36-Item Short Form
Health Survey (SF-36; first version), a self-adminis-
tered questionnaire, including 36 questions with 8
different aspects: physical functioning, physical role
functioning, bodily pain, general health, vitality, social
functioning, emotional role functioning, and mental
health. Raw points are transformed into a score from
0 to 100 for each dimension, with 100 reflecting the
best possible HRQOL.18
Statistical Analysis
Version 15.0 of the SPSS software package (SPSS Inc,
Chicago, IL) was used for the statistical analysis. The
primary outcome measure was FEV1. Including 160
patients per group would yield 80% power (α = .05)
to detect a 10% difference (88% vs 80% of preoperative
values) in FEV1 between groups, assuming a standard
deviation of 25%. Since dropout rate was anticipated
to be up to 10% to 15%, another 20 patients were
included in each group. Preoperative and postopera-
tive values were compared using Student paired t test
Deep Breathing Exercises / 37
12/14/13 7:28 PM
 or the Wilcoxon signed rank test. To ascertain differ-
T a b l e 2 • Demographic and Surgical
ences between groups, Student unpaired t test, the
Dataa
Mann-Whitney U test, or a χ2 test was used. All results
refer to 2-sided tests, and P values <.05 were consid- Breathing Control
ered significant. Group Group
(n = 159) (n = 154)
Men/women 129/30 126/28
RESULTS Age, y 67 ± 9 67 ± 11
2
BMI, kg/m 27 ± 4 27 ± 4
Of the 357 randomized patients, a total of 313 patients
b
(n = 149 at Uppsala University Hospital, and n = 164 Never smoked/exsmoker/smoker 68/85/6 71/77/6
at Örebro University Hospital) were analyzed (Figure Airway obstructionc 58 51
1). Reasons for withdrawal after randomization (n = NYHA class:
44) are presented in Table 1. Demographic and surgi- I-II/III-IV/missing value 67/82/10 54/83/17
cal data did not significantly differ between the 2 Left ventricular EF, % 54 ± 9 54 ± 10
groups (Table 2). The groups showed no significant
difference in length of hospital stay (10 ± 5 vs 10 ± CABG/valve/CABG + valve 52/77/30 54/76/24
4 days; P = .344). Operation time, h 4±1 4±1
ECC time, min 112 ± 49 115 ± 52
Lung Function Measurements
AoO time, min 79 ± 39 80 ± 41
Preoperative lung function was normal as related to
the predicted values (vital capacity [VC]: 91 ± 15% Left pleural space entered 41 48
predicted; FEV1: 90 ± 17% predicted). Two months Bilateral pleural space entered 22 20
postoperatively, a mean decrease in VC to 94 ± 11% Postoperative mechanical 6±4 6±3
(P < .001) and in FEV1 to 93 ± 12% (P < .001) of ventilation, h
preoperative values was found. There were no sig-
Abbreviations: AoO, aortic occlusion; BMI, body mass index; CABG,
nificant differences between the breathing group and coronary artery bypass grafting; ECC, extracorporeal circulation; EF,
control group either preoperatively or 2 months post- ejection fraction; FEV1, forced expiratory volume in 1 second; FVC, forced
vital capacity; NYHA, New York Heart Association.
operatively (Table 3). a
Data are presented as mean ± SD or number (n) of patients. No significant
differences between groups.
Peripheral Oxygen Saturation b
Missing data
No significant differences in saturation of peripheral c
Patients with preoperative FEV1/FVC < 0.70 were defined as having
oxygen either before (97.1 ± 1.5% vs 97.2 ± 1.5%; airway obstruction.
P = .661) or 2 months after surgery (97.4 ± 1.6% vs
97.6 ± 1.5%; P = .661) between the groups were
found. Thoracic Excursion
Thoracic mobility, measured as difference in size of
thoracic cage between inspiration and expiration, did
T a b l e 1 • Causes of Exclusion From the not differ significantly between the groups either before
Study After Randomization (n) (4.3 ± 2.0 cm vs 4.5 ± 2.2 cm; P = .548) or 2 months
Breathing Control after surgery (4.2 ± 2.2 cm vs 4.4 ± 2.1 cm; P = .547).
Group Group
Subjective Perception of Breathing Exercises
(n = 21) (n = 23)
and Pain
Hemodynamic instability 1 2
In the breathing group, 72% perceived benefit from
Pericardial or pleural effusion 3 2 the exercises. In addition, 81% reported that the
Sternal instability/infection 2 breathing exercises made it easier to take deep
Pain 1 breaths, and 83% reported that the breathing tech-
nique was easy to perform. Discomfort related to the
Cough 1
exercises was reported by 2% to a high degree and
Fatigue 3 2 17% to some extent. Adverse perceptions were related
Other morbidities 2 to increased pain and dizziness. Patients reported hav-
Failure to cooperate 1
ing performed the breathing exercises 4 ± 3 times
(range 3-5) a day postoperatively and that each ses-
Unwillingness to perform followup 13 11 sion had consisted of 23 ± 12 (range 3-60) breaths.

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 T a b l e 3 • Lung Function Data Preoperatively and 2 Months After Cardiac Surgerya
2-Month Values in Difference
2 Months Percentage of Preoperative Between
Before Surgery After Surgery Values Groups
Regarding
Change After
Breathing Control Breathing Control Breathing Control 2 Months
Group Group Group Group Group Group (95% CI) P Value
VC, L 4.0 ± 1.1 4.1 ± 1.0 3.7 ± 1.0 3.8 ± 1.0 93 ± 12% 94 ± 10% 1% .38
(−1 to 4)
FVC, L 3.8 ± 1.1 3.9 ± 1.0 3.5 ± 1.0 3.7 ± 1.0 94 ± 12% 93 ± 11% −1% .61
(−3 to 2)
FEV1, L 2.8 ± 0.8 2.9 ± 0.8 2.6 ± 0.7 2.7 ± 0.8 93 ± 13% 92 ± 10% −1% .53
(−4 to 2)
FEV1/VC, % 71.3 ± 8.4 72.2 ± 8.3 71.1 ± 9.5 70.9 ± 8.7 100 ± 11% 98 ± 8% −2% .10
(−4 to 0)
IC, L 3.0 ± 0.8 3.1 ± 0.8 2.8 ± 0.8 2.9 ± 0.7 94 ± 17% 94 ± 13% −0% .95
(−4 to 3)
FRC, L 3.4 ± 0.8 3.5 ± 0.9 3.3 ± 0.8 3.4 ± 0.8 97 ± 11% 98 ± 13% 1% .64
(−2 to 3)
RV, L 2.5 ± 0.6 2.6 ± 0.7 2.4 ± 0.6 2.4 ± 0.6 98 ± 15% 96 ± 14% −2% .22
(−6 to 1)
TLC, L 6.4 ± 1.3 6.6 ± 1.4 6.1 ± 1.3 6.3 ± 1.3 95 ± 10% 95 ± 11% 1% .50
(−2 to 3)
Abbreviations: FEV1, forced expiratory volume in 1 second; FRC, functional residual capacity; FVC, forced vital capacity; IC, inspiratory capacity; RV, residual
volume; TLC, total lung capacity; VC, vital capacity.
a
Data are presented as mean ± SD (95% CI of the difference). P values refer to the difference between breathing group and control group 2 months after
surgery regarding the relative changes in lung function (2-month values as percentage of preoperative values) (P < .05).

Median (range) values for both groups regarding pain
from the sternotomy (Numerical Rating Scale) were 0
(0-7) at rest, 1 (0-7) while taking a deep breath, and 2
(0-9) while coughing. No significant differences
between groups were present at rest (P = .306), while
taking a deep breath (P = .681), or while coughing
(P = .382).
Patient-Perceived Quality of Recovery
Two months postoperatively, QOR-40 scores had
improved from baseline (fourth postoperative day) in
both groups (breathing group: from 160 ± 17 to 178
± 14; control group: from 163 ± 17 to 181 ± 13; P <
.001). There was no significant difference between the
groups (P = .924).
Health-Related Quality of Life
Both groups showed a significant improvement in 5
of the 8 aspects of SF-36 2 months postoperatively
compared with preoperative values as shown in
Table 4. The change in HRQOL did not differ signifi-
cantly between the groups 2 months postoperatively
(Table 4).
Postoperative Pulmonary Infections
Two months postoperatively, 13 patients in the
breathing group and 15 in the control group reported
that they had any respiratory tract infection or pneu-
monia following surgery (P = .595). Antibiotic treat-
ment for respiratory tract infection/pneumonia was
reported by 6 patients in the breathing group and 13
in the control group (P = .070). Finally, 13 patients in
the breathing group and 19 in the control group
reported having sought medical treatment for respira-
tory tract infection/pneumonia during the study peri-
od (P = .204).
DISCUSSION
We have shown that home-based deep breathing
exercises 2 months after cardiac surgery did not result
in significant effects on lung function, oxygenation,
subjective perceptions, or HRQOL, compared with a
regime without breathing exercises after discharge. It
is worth noting that the reported use of antibiotic
treatment for respiratory tract infection/pneumonia

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 T a b l e 4 • Pre- and Postoperative 36-Item Short Form Health Survey Scores After Cardiac Surgerya
Before Surgery 2 mo After Surgery Difference Between
Groups Regarding Change
Breathing Control Breathing Control in Score After 2 mo
Group Group P Value Group Group P Value (95% CI) P Value
PF 62.2 ± 25.0 63.0 ± 23.4 .76 70.0 ± 20.6 74.4 ± 17.8 .06 −3.5 (−8.6 to 1.6) .18
RP 35.4 ± 40.5 31.4 ± 40.3 .39 24.3 ± 34.9 26.1 ± 37.9 .68 −8.9 (−20.6 to 2.8) .14
BP 69.5 ± 26.3 67.9 ± 26.6 .59 67.1 ± 23.2 67.3 ± 24.3 .95 −2.0 (−8.9 to 4.9) .57
GH 63.2 ± 19.1 62.8 ± 17.6 .86 73.2 ± 17.6 74.0 ± 19.5 .70 −2.2 (−6.1 to 1.7) .27
VT 50.8 ± 23.3 52.1 ± 24.0 .64 63.7 ± 19.8 66.2 ± 19.6 .27 −2.0 (−7.3 to 3.3) .45
SF 76.9 ± 24.6 77.5 ± 25.2 .84 81.2 ± 21.3 81.6 ± 23.0 .87 −1.8 (−7.6 to 3.9) .53
RE 63.5 ± 42.0 62.9 ± 43.7 .91 66.7 ± 41.3 67.1 ± 42.9 .92 −3.0 (−15.2 to 9.1) .62
MH 72.7 ± 18.7 74.9 ± 18.6 .31 80.8 ± 15.1 82.3 ± 16.2 .41 0.7 (−3.3 to 4.7) .74
Abbreviations: BP, bodily pain; GH, general health; MH, mental health; PF, physical functioning; RE, emotional role functioning; RP, physical role functioning;
SF, social functioning; VT, vitality.
a
Data are presented as mean ± SD (95% CI of the difference). P values refer to the difference between the breathing group and the control group 2 months
after surgery regarding the changes (difference before and after surgery) of 36-Item Short Form Health Survey score (P < .05).

was more than twice as high in the control group as
in the breathing group and 5 more patients in the
control group reported having sought medical treat-
ment for respiratory tract infection/pneumonia or
other lung problems during the study period. However,
none of these results were statistically significant, and
the self-reported signs of respiratory tract infection/
pneumonia were neither verified by the researchers
nor coupled with the identification of pathogenic bac-
teria. Hence, these results should be interpreted with
caution.
In earlier publications, we reported effects of
breathing exercises on atelectasis,1,6 oxygenation,6,7
and lung function1 in the immediate period after car-
diac surgery, and these results have since been sup-
ported by others.2,19,20 However, there is no scientific
evidence of how long exercises should be continued
after surgery. The optimal intensity, technique, and
device remain unclear. Arbitrary instructions are
given, and recommendations vary between hospitals.5
Mobilization and deep breathing exercises are used to
increase lung volume and improve oxygenation after
surgery.1,8,19,21 There are also several mechanical
devices in use to improve lung function. Most investi-
gations involving mechanical devices after cardiac
surgery have examined incentive spirometry (IS)4,22,23
and intermittent positive pressure breathing,24,25 but
there is little scientific evidence to support one tech-
nique over another. In general, few studies have
evaluated breathing exercises performed after dis-
charge.8,19 Haeffener et al19 and Ferreira et al8 evalu-
ated IS combined with PEP performed for 15 to
20 minutes twice a day from the first postoperative
day to 1 month postoperatively. Improvement in lung
function,19 sensation of dyspnea after 6-Minute
Walking Test, and improved HRQOL,8 were found
1 month postoperatively.
The expiratory resistance method (PEP) used in the
present study is thought to slow down expiration and
increase lung volume and may prevent or reduce air-
way collapse. The PEP technique combined with IS
has shown positive outcomes on lung function,
6-minute walking distance, and postoperative pulmo-
nary complications,19 as well as dyspnea and SF-36
scores 1 month after surgery.8 The combination of an
initial deep inspiration with the expiratory resistance
could possibly extend time at a higher lung volume,
and this may help expand and maintain alveolar and
airway patency, as well as re-expansion of atelecta-
sis.1,6 The effects achieved in the studies by Haeffener
et al19 and Ferreira et al8 could possibly be attributed
to the use of IS, which helps the patient to visualize
the inspiratory volume. In the present study, the
patients performed the breathing exercises at home
without any further supervision after discharge, which
might be one explanation for failure of treatment
effects.
The frequency of 30 deep breaths per session was
chosen according to the ordinary routines. An
increased frequency is likely to be more efficacious,
and we found a total of 150 breaths a day reasonable.
As in the study by Ferreira et al,8 the patients were
contacted by telephone to emphasize the importance
of executing the exercises. The reported training per
day was fairly high (range 3-5), even though it was
not possible to distinguish the exact number of

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JCRP-D-13-00025.indd 40 12/14/13 7:28 PM

 breathing exercises actually performed. This uncer-
tainty is a limitation that the present study has in com-
mon with other evaluations of nonsupervised home-
based exercise training.
Patients undergoing cardiac surgery have a high
risk of pulmonary complications postoperatively.26
Decreases in lung function have been described sev-
eral months after surgery, and hence optimization of
postoperative treatment is a task of high priority.27-29
A greater responsibility for the postoperative rehabili-
tation and recovery is likely to take place in patient
home.30 Further evaluation of subgroups at higher risk
for postoperative lung complications is warranted,
before a final conclusion can be reached concerning
the benefit of breathing exercises after discharge.
Two months postoperatively, patients showed a
restrictive pulmonary impairment with a mean decrease
in FEV1 to 93% of preoperative values. Pain from the
sternotomy was low 2 months postoperatively, and
SF-36 scores increased compared with preoperative
values. Home-based deep breathing exercises for
2 months following cardiac surgery did not result in
improved lung function, patient-perceived quality of
recovery, or HRQOL, even though most patients per-
ceived a subjective benefit from the exercises.
CONCLUSIONS
We found no effects of home-based deep breathing
exercises performed after cardiac surgery; however,
the clinical importance of breathing exercises after
discharge needs to be further determined. The grow-
ing number of older and chronically ill patients is a
challenge to surgery and postoperative rehabilitation,
and further research should be designed to help iden-
tify patients who may benefit the most from breathing
interventions after discharge.
Acknowledgments
Financial support was provided by grants from the
Research Committee of Örebro County Council, the
Swedish Heart Lung Foundation, the Swedish Heart
and Lung Patients National Association, the Swedish
Research Council (Reg. no. 2009-1385), Uppsala
University, and Uppsala-Örebro Regional Research
Council, Sweden.
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