598 ANESTH ANALG
1989;69:59W03
Abdominal Muscle Activity and Intraabdominal Pressure after
Upper Abdominal Surgery
John E. Duggan, MBBS, FFARCS and Gordon B. Drummond,
DUGGAN JE, DRUMMOND GB. Abdominal muscle
activity and intraabdominal pressure after upper
abdominal surgery. Anesth Analg 1989;69:598-603.
To examine the influence of abdominal muscle activity on
intraabdominal pressure, the integrated surface EMG from
upper abdominal muscle ( E A R ) was related to changes in
intragastric pressure (PGA) in six patients after upper
abdominal surgery. A similar respiratory pattern of EMG
activity was observed in all subjects. E A R increased rapidly
at the onset of expiration, and thereafter more slozoly
throughout expiration. A t the onset of inspiration E,,
decreased abruptly, and was small during inspiration.
Patients undergoing upper abdominal surgery fre-
quently develop abnormal respiratory function after
operation with reduction in end-expiratory lung vol-
ume that has been attributed, in part, to reflex spasm
of the abdominal muscles (1). We have shown that
after abdominal surgery there is frequently an in-
crease in abdominal muscle activity during expiration
in the abdominal and lower intercostal muscles (2).
However, the mechanical effect of muscle activity
was not directly measured in that study. The present
study was designed to assess the effects of changes in
abdominal muscle activity on the time-course of in-
traabdominal pressure during breathing in patients
after upper abdominal surgery. This relationship is
important because of the suggestion that diaphrag-
matic activity is impaired by abdominal operation,
based on observations of changes in abdominal pres-
sure with breathing (3).
Methods
We studied six otherwise healthy patients, of either
sex, who had undergone elective operations for cho-
Received from the Department of Anaesthetics, Royal Infir-
mary, Edinburgh, Scotland. Accepted for publication June 9, 1989.
Address correspondence to Dr. Drummond, Department of
Anaesthetics, Royal Infirmary, Lauriston Place, Edinburgh EH3
9YW, Scotland, UK.
01989 by the International Anesthesia Research Society
MA, FFARCS
Changes in intragastric pressures were closely related to
changes in EAR. In fizle patients P,, and EAR waveforms
were almost identical over the respiratory cycle. In one
subject a biphasic change in PGA during inspiration was
observed, suggesting the influence of other respiratory
muscles. Abdominal muscle action results in changes in
intraabdominal pressure previously attributed to diaphrag-
matic impairment.
Key Words: MEASUREMENT TECHNIQUES,
ELECTROMYOGRAPHY. MUSCLE,
ABDOMINAL-pattern of activity postoperatively.
SURGERY, ABDOMINAL.
lecystectomy ( n = 3) or gastric procedures ( n = 3).
They were free from respiratory disease and had
given informed verbal consent for the study. The
study was approved by the local ethics advisory
committee, which did not require that written con-
sent be obtained.
Anesthesia was standardized. Premedication was
with oral temazepam 20 mg 2 hr before surgery.
Anesthesia was induced with thiopental 4-7 mg/kg
and maintained with enflurane (1-2% inspired con-
centration) and nitrous oxide (70% inspired concen-
tration) in oxygen. Tracheal intubation was facilitated
with succinylcholine, and muscle relaxation was ob-
tained with alcuronium and was antagonized at the
end of the procedure with neostigmine. Complete
reversal of neuromuscular blockade was confirmed
by stimulation of the ulnar nerve. After recovery from
anesthesia, morphine was given IV for pain relief (up
to 10 mg) with analgesia thereafter maintained with
an infusion of morphine sulfate (up to 1 mgkg over 24
hr, supplemented if necessary with small IM doses.
Three hours after surgery, simultaneous record-
ings of intragastric pressure (PGA),abdominal muscle
EMG activity (EAg:), nasal airflow, and the electrocar-
diogram (ECG) were made over a 10-min period
during quiet tidal breathing with the patient in the
supine position.
ABDOMINAL PRESSURE AND MUSCLE ACTIVITY
Table 1. Patient Characteristics and Surgical Details
Age Height
Sex (years) ( 4
F 51 163
M 64 168
M 37 179
M 38 177
F 48 175
F 39 177
Chole: cholecystectomy;HSV: highly selective vagotomy; and RUQ: right upper quadrant.
Intragastric pressure was measured using a trans-
ducer (Sanborn 207a, Waltham, MA) attached by a
sidearm to a nasogastric tube (14 FG) with its tip
positioned in the stomach. The tube was first flushed
with physiologic sodium chloride solution and then
kept patent with a slow constant infusion of sodium
chloride solution at 10 mL/hr. Measurement of PGA in
this way avoided the introduction of an intragastric
balloon in addition to the nasogastric tube already in
place. This method gives measurements of intragas-
tric pressure which correlate well with the gastric
balloon method (4,5).
Nasal airflow was measured using the method of
Guyatt and coworkers (6). Oxygen was administered
at 2 L/min by nasal cannulae positioned within the
external nares of the patient. These cannulae also
acted as nasal pitot tubes. Pressure fluctuations at a
sidearm at the upstream end of the supply tube were
measured with a differential pressure transducer,
which was connected between the sidearm and a
balance reference tube that also carried an oxygen
flow. The bias flow was adjusted so that when no
flow was present at the nose the pressure difference
across the transducer was zero. This method was
validated as a qualitative index of the phases of
respiration by comparison of the flow signal with
measurements of rib cage and abdominal motion
using impedance bands around the rib cage and
abdomen, and it gave an accurate index of the phases
of respiration. The nasal flow signal was used to
identify three phases of the respiratory cycle: inspi-
ration (I), expiration (E), and an expiratory pause
(EP).
Abdominal muscle EMG was measured using two
pregelled silver-silver chloride electrodes with 1 cm
diameter pads (Medicotest). The skin was prepared
with an abrasive jelly and an organic solvent so that
the interelectrode resistance was typically less than 2
k 0 . The electrodes were placed with their centers 4
cm apart, 2 cm below the left costal margin, lateral to
the mass of the rectus abdominis, so that the activity
they picked up was predominantly that of the exter-
nal oblique muscle. A reference electrode was placed
ANESTH ANALG 599
1989;69:598403
Weight
(kg) Operation Incision
64 Chole RUQ transverse
72 Chole RUQ transverse
67 HSV Upper midline
65 HSV Upper midline
82 Chole RUQ transverse
79 HSV Upper midline
on the iliac crest. The EMG signal was amplified and
filtered with a bandwidth of 20 Hz to 2 kHz (Neu-
rolog NL 104/125, Digitimer Ltd., Welwyn Garden
City, Herts, UK) and recorded with an FM tape
recorder (Digitimer D146) along with the ECG (lead
11), PGA, and nasal airflow signals. Zero activity for
the EMG signal was recorded at the end of each
assessment by placing the electrodes face to face.
The recorded signals were played back onto a UV
galvanometer recorder (Bell and Howell 5-137, Bas-
ingstoke, Herts, UK). The EMG signal was passed
through a delay network, and, using a method sim-
ilar to that described by Muller and coworkers (7), the
contribution of the ECG artifact was gated out. The
signal was then full wave rectified and integrated as
an exponential time weighted average using a "leaky
integrator" (NL 103) with a time constant of 100 mS.
The EMG signals were calibrated by passing a known
voltage through the same network to the recorder.
In each patient 30 consecutive breaths were ana-
lyzed in detail. The relationship between E,B and
PGA was assessed by measuring the changes in these
values that occurred during inspiration, expiration,
and the expiratory pause, and interrelating those
changes by means of least squares linear regression
analysis (8).
Results
Details of patient characteristics and operations per-
formed are given in Table 1. A representative sample
of nasal airflow and PGA and EA, signals in a subject
after cholecystectomy is illustrated in Figure 1. The
phases of each breath (I, E, and El') are identified by
changes in nasal airflow and separated by the dashed
lines A, B, C, and D. The changes in PG, and E A B that
occurred over these phases were measured by sub-
tracting the value at the beginning of each phase from
the value at the end of that phase: a negative value
indicates a decrease in the variable over the respira-
tory phase under study. For example, the change in
PGA that occurred over inspiration in Figure 1 is
600 ANESTH ANALG
1989;69:59%603
Nasal Airflow
Figure 1 Representative record of nasal airflow, intragastric pres-
I
sure (P,,), and abdominal muscle activity (EAB) (amplification
before integration 10K). The phases of each breath are identified by
changes in nasal airflow and separated by the dashed lines. A.
onset of inspiratory airflow; B: onset of expiratory airflow; C: end
of expiration; and D: onset of next inspiration.
obtained by subtracting the value of PGA at point A
(onset of inspiratory flow) from the value at point B
(onset of expiratory flow).
Phasic activity of the abdominal muscles in time
with respiration can be seen in the recording of E A B
illustrated in Figure 1. This pattern was present
throughout the observation period in all six patients
studied. The following features were seen consis-
tently: 1) There was little detectable EMG activity
during inspiration; 2) E A g increased rapidly with the
onset of expiratory airflow; 3) there was a subsequent
progressive increase in EAB throughout expiration
and the expiratory pause; and 4) E A g decreased
abruptly at the onset of inspiratory airflow. In Figure
1, it can be seen clearly that the variations in PGA over
a respiratory cycle resemble the variations in EAB over
the same cycle. At the onset of inspiratory airflow,
PGA shows a rapid decrease, which can be related in
time to the change in EAg. PGA continues to decrease
throughout most of the duration of inspiration, al-
though at a much slower rate, reaching a nadir in late
inspiration. An increase in PGA was noted commonly
just before the onset of expiratory airflow, followed
by a progressive increase in pressure throughout
expiration and the expiratory pause. The mean
changes in PGA and EAB over 30 consecutive single
breaths for the different phases of respiration in each
subject are shown in Figure 2. For subjects 1 through
5, the similarity in the waveform of PGA and E A B in
individual subjects is indicated by the common pat-
tern of the mean changes in PGA and E A g . However,
in patient 6 this relationship is not evident, despite a
similar phasic pattern of abdominal muscle activity.
Subject 6 showed a more complex PGA waveform,
with a biphasic pressure change during inspiration
DUGGAN AND DRUMMOND
14.
---
I E EP 1
Respimtor y
cycle
Figure 2. Mean changes (SD) in E,, (a.u.) and in PGA (cm H,O)
observed over the different phases of respiration (I: inspiration; E:
expiration; EP: expiratory pause) in 30 consecutive single breaths
for each subject.
4 74 7
Y
w
Figure 3 . Nasal airflow, intragastric pressure (PGA),and abdomi-
nal muscle activity (EAB) (amplification before integration 20K)
recorded from subject 4 , in whom a biphasic pressure change was
observed during inspiration. Three separate breaths are shown
that differ in the amount of end-expiratory abdominal muscle
activity (increasing from left-hand to right-hand traces). There is a
consistent increase in ,)I in late inspiration, and P, is otherwise
closely related to changes in EAB.
(Figure 3 ) . As in the other five subjects, PGA de-
creased at the start of inspiration and was related in
magnitude to the decrease in EAg. However, this
initial decrease in F'GA was consistently followed by a
positive pressure wave, beginning in late inspiration
and becoming maximal at the end of inspiratory
airflow. The three breaths illustrated in Figure 3 were
chosen to show different degrees of end-expiratory
muscle activity, lew in the left-hand and more in the
right-hand tracing:;. In each of these three breaths, at
the onset of inspiration, the magnitude of the initial
decrease in PGA can be related to the magnitude of
change in EAg, which is progressively greater from
left-hand to right-hand tracings. The positive pres-
sure wave can be seen clearly in late inspiration in
each breath, with a similar amplitude and time-
course. Thus, in the three sample breaths shown, the
overall change in P , during inspiration consists of
the initial decrease and the late positive wave. When
the initial decreasing component of PCAis small, as in
ABDOMINAL PRESSURE AND MUSCLE ACTIVITY
L L
the first breath, the overall change in P, during
inspiration is positive. In breaths 2 and 3, as the initial
decreasing component of PG, becomes greater, the
overall change in P G A over inspiration at first de-
creases within the positive range (breath 2), and then
becomes negative (breath 3).
Examination of recordings, and mean values cal-
culated from all the breaths analyzed, of the changes
in P G A and E A B during each part of the respiratory
cycle indicated that between patients, the degree of
change in PGAwas related to changes in EAB. How-
ever, each patient had considerable breath-to-breath
variation in the changes noted for each of these
variables. Consequently, the use of mean values
obtained from each patient over a number of breaths
obscures the exact relationship of P G A and EAB. To
examine this relationship further, and to assess the
relative contribution of the pattern of abdominal
muscle activation to changes in intragastric pressure,
we plotted for each patient the changes in E A B and
P G A observed in each phase of the respiratory cycle
for 30 consecutive breaths (Figure 4). The slopes of
the regression lines of the E A B and P G A plot for each
phase of respiration, and the coefficients of linear
regression of these relationships, are given in Table 2.
ANESTH ANALG 601
1989;69:598-603
Figure 4. Plots of changes in P, (cm H,O) and E,, (a.u.) over
each phase of respiration for 30 consecutive single breaths. Each
column represents another patient, from patient 1 (on the left)
through patient 6 (on the right). Top row: inspiration; middle row:
expiration; and bottom row: expiratory pause. The regression lines
are shown. Regression details are given in Table 2.
In each patient there was a close relationship between
the changes in E A B and P G A during I, E, and El’. The
slopes of the regression lines obtained in each phase
of respiration were similar in individual patients. In
patients 1 through 5, the intercepts of the regression
lines are close to the origin of the plot of E A B and PGA.
In addition, some observed points fall close to the
origin of the plot, suggesting that when the activity of
the abdominal muscles did not change during the
respiratory cycle, the change in intraabdominal pres-
sure associated with respiration was small. Although
a similar correlation between changes in EA, and P G A
was present in patient 6, Figure 4 shows that in this
patient the relationships of E A B and PGAdid not pass
close to the intercept of the plot. For inspiratory
changes, the regression line was shifted to the left,
and for the expiratory changes the line was shifted an
equivalent amount to the right, although the slopes
of the regression lines remain similar.
602 ANESTH ANALG
1989;69:59&603
Table 2 . Regression Relationships for Changes in PGAand E,,
Linear regression coefficient
Subject I E
1 0.84 0.57
2 0.59 0.56
3 0.72 0.63
4 0.84 0.80
5 0.73 0.6
6 0.78 0.56
I inspiration, E expiration, and El‘: expiratory pause
Discussion
In this study we consistently observed expiratory
activity of the muscles of the upper abdominal wall.
This confirms the findings in a previous study (2) in
which 18 similar patients showed the same pattern of
muscle activity, in the lower intercostal, upper ab-
dominal, and lower abdominal muscles. This sug-
gests that the muscles surrounding the abdominal
contents usually have phasic respiratory activity after
upper abdominal surgery.
It is clear from the similar time-course of the
changes in PGA and EA, during breathing, and the
individual linear correlations between the breath-
to-breath changes in these two variables (Figure 4),
that this phasic pattern of abdominal muscle activity
directly affects intraabdominal pressure. The magni-
tude of the changes of P,, associated with the
variations in EMG activity suggests that this pattern
of abdominal muscle action has a significant influence
on the mechanics of breathing. Expiratory activity of
the abdominal muscles has also been reported in
dogs up to 1 hr after cholecystectomy (9). In normal
humans, expiratory activity of the abdominal muscles
is only found when minute ventilation is great (10-12).
However, the abdominal muscles become active in
humans during expiration when breathing is unstim-
ulated in the lightly anesthetized state (13). In that
study, performed in volunteers without surgical stim-
ulation, the pattern of PGA change was remarkably
similar to that observed in the present study after
upper abdominal surgery. The present study was
performed 3 hr after recovery from anesthesia and
conducted with agents associated with rapid recov-
ery, so that residual effects of the anesthetic agents
are unlikely to have been responsible for the findings
of this study.
Breathing influences intraabdominal pressure by
the action of inspiratory muscles, both those of the rib
cage and those of the diaphragm. Inspiratory activity
of these two muscle groups has opposite effects on
intraabdominal pressure: diaphragmatic contraction
increases intraabdominal pressure, whereas inspira-
DUGGAN AND DRUMMOND
for Each Patient in Each Phase of Respiration
!Slope of regression line (cm H,O/a.u.)
EP I E EP
0.82 0.43 0.35 0.32
0.25 0.17 0.11 0.05
0.46 0.19 0.21 0.13
0.4 0.12 0.11 0.16
0.68 0.17 0.16 0.17
0.62 0.37 0.37 0.10
tory action of the muscles of the rib cage reduces
intraabdominal pressure. In normal subjects in the
supine posture inspiration is predominantly a result
of diaphragmatic activity, and intraabdominal pres-
sure increases during inspiration (14). In subjects 1
through 5, because intraabdominal pressure changed
little during inspirations when there was little change
in abdominal muscle activity, both the rib cage mus-
cles and diaphragm must have been active during
inspiration, and acting in a way to minimize the
transmission of the decrease in pleural pressure to
the abdominal cavity. In the sixth subject, intraab-
dominal pressure increased in late inspiration, and
there was evidence on the EA,/PG, plot of an inde-
pendent factor that influenced PGA; this suggests that
muscles exerting a positive influence on PGA were
active at the end of inspiration, which is consistent
with either a greater action of the diaphragm or
relatively less action of rib cage muscles during inspi-
ration in this subject compared to the others.
Activity of the abdominal muscles can reduce lung
volume, both directly, because of their insertion at the
lower rib cage, and indirectly, by displacing the re-
laxed diaphragm cranially secondary to increases in in-
traabdominal pressure. The abrupt offset of abdominal
muscle activity can thus contribute to inspiration, if ex-
piratory activity of the abdominal muscles has reduced
the volume of the respiratory system to less than the
passive functional residual capacity. This is observed
in patients with bilateral phrenic nerve palsy (15).
A sudden reduction of abdominal muscle activity
at the onset of inspiration may impair the action of
the diaphragm. Contraction of the diaphragm is
normally accompanied by elevation of the lower rib
cage, and this effect is dependent on the ”fulcrum
effect” of the abdominal contents (16), whereby the
increase in intraabdominal pressure caused by the
tense diaphragm also generates a lateral force on the
lower rib cage. Thus a reduction in intraabdominal
pressure associated with the offset of abdominal
muscle activity, when diaphragmatic activity is in-
creasing, may result in a less efficient mechanical
ABDOMINAL PRESSURE AND MUSCLE ACTIVITY
coupling of diaphragmatic contraction to lower rib
cage movement.
It is evident that expiratory abdominal muscle
recruitment has to be considered in the analysis of
respiratory impairment after abdominal surgery. Sev-
eral methods of analysis have been advanced. Two
are based on the relative pressure changes in abdom-
inal and pleural compartments: the "diaphragmatic
index" used by Gilbert, Auchincloss, and Peppi (17),
which is the ratio between changes in intraabdominal
pressure during inspiration and the change in trans-
diaphragmatic pressure over the same period (APAB/
APDI),and the index used by Ford and colleagues (3)
of the ratio between the change in abdominal pres-
sure and the change in pleural pressure during inspi-
ration (APAB/APpL). A further index is based on the
analysis by Konno and Mead of the motion of the rib
cage and abdomen during breathing (18), and is
expressed as the relative change in dimensions of the
rib cage (RC) and abdomen (AB) [AAB/(AAB+ARC)].
After abdominal surgery, changes in both the pres-
sure indices (3,19,20) and the motion index (3,21)
have been interpreted as showing a marked degree of
diaphragmatic impairment. Epidural analgesia with
bupivacaine causes these indices to change toward
the preoperative values (22).
The above indices of pressure and motion attempt
to assess the relative action of the diaphragm and rib
cage muscles in a system in which the abdominal
muscles may also contribute to both pressure and
movement. If the abdominal muscles have phasic
respiratory activity, such as after abdominal surgery,
these indices are unlikely to be of value. For example,
a reduction in abdominal muscle activity on inspira-
tion will yield pressure indices suggesting greater rib
cage activity, because these muscles have an opposite
action on intraabdominal pressure. We conclude that
phasic respiratory activity of the abdominal muscles
is common after abdominal surgery. Abdominal mus-
cle action should be considered in the analysis of
respiratory movement and pleural and abdominal
pressure changes after abdominal surgery. Previous
conclusions concerning postoperative diaphragmatic
activity need to be reevaluated in light of these
findings.
We wish to thank Mr. I.B. Macleod for the opportunity to study
patients in his care and the ward staff for their interest and
assistance.
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