ORIGINAL ARTICLE ISSN 0103-5150

Fisioter. Mov., Curitiba, v. 31, e003106, 2018

DOI: http://dx.doi.org/10.1590/1980-5918.031.AO06
Licensed under a Creative Commons attribution

[T]

Evaluation of the effectiveness of preoperative outpatient

pulmonary preparation in patients undergoing esophageal surgery

Avaliação da efetividade do preparo pulmonar ambulatorial

no período pré-operatório de cirurgia do esôfago

Evaluación de la efectividad del preparo pulmonar ambulatorial

en el período pre-operatorio de cirugía del esôfago

Fernanda Maria Rodrigues da Cunha[a], Marisa de Carvalho Borges[a], Júlia Maria Vergani Fanan[a],
Paulo Fernando de Oliveira[a], Márcia Souza Volpe[b], Eduardo Crema[a]*

[a]
Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil
[b]
Universidade de São Paulo (USP), São Paulo, SP, Brazil

[R]

Abstract

Introduction: Preoperative inspiratory muscle training (IMT) can minimize the occurrence of complications
after esophagectomy. Objective: To evaluate the effects of preoperative IMT in patients undergoing esophageal
surgery by determining respiratory muscle strength (PImax and PEmax), pulmonary function (FEV1, FVC,
FEV1/FVC) and functional capacity by the 6-minute walk test (6MWT). Methods: Twenty-two patients were
randomized into two groups: a control group (CG; n = 10) and an intervention group (IG; n = 12). Only IG

*
FMRC: MS, e-mail: [email protected]
MCB: PhD, e-mail: [email protected]
JMVF: MS, e-mail: [email protected]
PFO: PhD, e-mail: [email protected]
MSV: PhD, e-mail: [email protected]
EC: PhD, e-mail: [email protected]
Fisioter Mov. 2018;31:e003106 Page 01 of 10
 Cunha FMR, Borges MC, Fanan JMV, Oliveira PF, Volpe MS, Crema E.
2

performed IMT for a minimum period of 2 weeks. The assessments were conducted pre- and post-surgery.
Results: An increase of PImax was observed in IG, but not in CG, in the second preoperative assessment (p =
0.014). Assessment on postoperative day 1 showed a reduction in maximal respiratory pressures in the two
groups, but the reduction was more marked in IG (p < 0.05). Partial recovery of the variables evaluated was
observed at discharge in the two groups. These variables had fully returned to initial values on postoperative
day 30. The distance walked in the 6MWT was greater in IG, but the difference was not significant (p =
0.166). There was no difference in the frequency of pulmonary complications between groups. Conclusion:
Preoperative IMT performed in our study improved inspiratory muscle strength but did not influence the
postoperative pulmonary function or functional capacity of patients undergoing esophagectomy.

Keywords: Low Back Pain. Epidemiology. Occupational Health. Military Personnel.

Resumo

Introdução: O treinamento muscular inspiratório (TMI), realizado no pré-operatório, pode minimizar a ocorrência
de complicações após esofagectomia. Objetivo: Avaliar os efeitos do TMI realizado no pré-operatório da cirurgia
do esôfago através da força muscular respiratória (PImáx e PEmáx), da função pulmonar (VEF1, CFV, VEF1/
CVF) e da capacidade funcional através do teste de caminhada de 6 minutos (TC6’). Métodos: 22 pacientes foram
randomizados em: Grupo Controle (GC; n = 10) e Grupo Intervenção (GI; n = 12). Somente o GI realizou TMI por
no mínimo 2 semanas. As avaliações foram realizadas no pré e pós-operatório. Resultados: Houve aumento da
PImáx no GI na 2° PRÉ (p = 0,014), enquanto no GC não houve alteração. Na avaliação do 1°PO os dois grupos
apresentaram redução das pressões respiratórias máximas, porém a redução foi mais acentuada no GI (p < 0,05).
Na alta hospitalar ocorreu recuperação parcial das variáveis avaliadas em ambos os grupos e no 30°PO ocorreu
recuperação plena em relação aos valores iniciais. Em relação ao TC6’ houve um aumento da distância percorrida
no GI, mas não foi significante (p = 0,166). Não houve diferença na ocorrência de CP entre os grupos. Conclusão: O
TMI realizado em nosso estudo melhorou a força muscular inspiratória, mas não influenciou a função pulmonar e a
capacidade funcional pós-operatória de pacientes submetidos a esofagectomia.

Palavras-chave: Fisioterapia. Terapia respiratória. Teste de Caminhada. Esofagectomia.

Resumen

Introducción: El entrenamiento muscular inspiratorio (TMI), realizado en el preoperatorio, puede minimizar

la ocurrencia de complicaciones después de la esofagectomía. Objetivo: Evaluar los efectos del TMI realizado
en el preoperatorio de la cirugía del esófago a través de la fuerza muscular respiratoria (PImáx y PEmáx),
de la función pulmonar (VEF1, CFV, VEF1 / CVF) y de la capacidad funcional a través del test de caminata
de 6 minutos (TC6‘). Métodos: 22 pacientes fueron randomizados en: Grupo Control (GC, n = 10) y Grupo
Intervención (GI; n = 12). Sólo el GI realizó TMI por lo menos 2 semanas. Las evaluaciones se realizaron en el
pre y postoperatorio. Resultados: Hubo aumento de la PImáx en el GI en el 2°PRÉ (p = 0,014), mientras que
en el GC no hubo alteración. En la evaluación del 1°PO los dos grupos presentaron reducción de las presiones
respiratorias máximas, pero la reducción fue más acentuada en el GI (p < 0,05). En el alta hospitalaria ocurrió
recuperación parcial de las variables evaluadas en ambos grupos y en el 30°PO ocurrió recuperación plena en
relación a los valores iniciales. En relación al TC6‘hubo un aumento de la distancia recorrida en el GI, pero no
fue significativo (p = 0,166). No hubo diferencia en la ocurrencia de CP entre los grupos. Conclusión: El TMI
realizado en nuestro estudio mejoró la fuerza muscular inspiratoria, pero no influenció la función pulmonar y
la capacidad funcional postoperatoria de pacientes sometidos a esofagectomía.

Palabras clave: Fisioterapia. Terapia respiratória. Prueba de Caminata. Esofagectomía.

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 Evaluation of the effectiveness of preoperative outpatient pulmonary preparation in patients undergoing esophageal surgery
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Introduction
Methods
Chagas disease is an important public health problem
since it continues endemic in several Latin American This was a randomized clinical trial conducted at
countries, with 16 to 18 million infected people and the Sector of Digestive Tract Surgery of the University
another 100 million at risk of contracting the disease. Hospital of Universidade Federal do Triângulo Mineiro
An estimated 10 million people are infected in Brazil. (HC-UFTM). Twenty-two male patients participated in
Each year, the disease kills an average of 17,000 people, the study. Ten patients were randomly assigned to the
with 60 million being at risk in 18 endemic countries [1]. control group (CG) and 12 to the intervention group
Eight to 40% of patients with Chagas disease develop (IG). With respect to diagnosis, four patients (40%)
different degrees of esophageal manifestations, which in CG had cancer and six (60%) had megaesophagus.
represent a large socioeconomic problem in Brazil and In IG, six patients (50%) had cancer and six had
reduce the quality of life of patients due to dysphagia, megaesophagus. Laparoscopic esophagectomy was
which is often severe [2]. the surgical procedure performed.
The etiological agent of Chagas disease, Trypanosoma Respiratory muscle strength was evaluated by
cruzi, destroys the nerve plexuses of the esophageal wall, assessing the following variables: maximal inspiratory
which results in reduced peristalsis and a hypertonic pressure (PImax) and maximal expiratory pressure
lower esophageal sphincter, causing achalasia (absence (PEmax) on PRE1 and PRE2, PO1, discharge and PO30;
of peristaltic movements in the esophagus and narrowing pulmonary function by forced expiratory volume in
of the cardia) and megaesophagus (dilatation of the the first second (FEV1), forced vital capacity (FVC)
esophagus) [3]. The main symptoms of megaesophagus and the ratio between these variables (FEV1/FVC) on
are dysphagia, bronchoaspiration of regurgitated food, PRE1, PRE2, discharge and PO30; functional capacity
weight loss, vomiting, excessive salivation, retrosternal by the six-minute walk test (6MWT) on PRE1, PRE2,
pain, and heartburn. Nighttime coughs, lung abscesses, discharge and PO30.
and airway infections may also occur. Chagasic The study was approved by the Ethics Committee
megaesophagus is more common in males and in the of UFTM (Approval No 1823). The data of each patient
age range of 30-40 years. The onset of dysphagia before were recorded on an assessment chart and all patients
the age of 40 is observed in 80% of cases [4]. provided written informed consent.
More advanced megaesophagus (grade IV) requires The criteria for inclusion of the patients were a
major surgery, with removal of the sick organ, i.e., diagnosis of megaesophagus (grades III and IV) or
esophagectomy, being the treatment of choice. This resectable esophageal cancer and age older than
approach is aimed at partially removing the esophageal 18 years. Patients operated upon within less than 2
body extensively compromised by the destruction of the weeks after initial evaluation and those who did not
myenteric plexuses that are responsible for motility and understand or did not adhere to the intervention
contraction of the esophagus [5]. However, although proposed were excluded.
surgery is the therapeutic procedure that provides the
best outcomes in these patients, it can cause important
pulmonary complications that delay the recovery of the First Preoperative Physiotherapeutic Evaluation
patients and even increase mortality [6]. (PRE1)
Pre- and postoperative respiratory physiotherapy has
been used successfully for the prevention of pulmonary During anamnesis, personal data, history of past and
complications in this type of surgery. According to a present disease, history of smoking and presence of
recent study [7], respiratory physiotherapy combined comorbidities, including pulmonary and heart diseases,
with respiratory muscle training is one of the most were collected. Physical examination consisted of the
promising preoperative interventions described. measurement of anthropometric variables (weight,
The objective of the present study was to evaluate height, and BMI). Respiratory muscle strength and pul-
the effects of preoperative inspiratory muscle training monary function were evaluated by the measurement
(IMT) in patients undergoing esophageal surgery on the of PImax and PEmax and by spirometry. Functional
development of postoperative pulmonary symptoms. capacity was evaluated by the 6MWT.

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 Cunha FMR, Borges MC, Fanan JMV, Oliveira PF, Volpe MS, Crema E.
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Second Preoperative Physiotherapeutic Evaluation (Jaeger®) to obtain the following variables: FVC, FEV1,
(PRE2) and FEV1/FVC. The test was carried out according to the
Guidelines for Pulmonary Function Tests of the Brazilian
The second physiotherapeutic evaluation (PRE2) Society of Pneumology and Tisiology. The reference
was performed up to 48 hours (1 or 2 days) before values reported by Pereira et al. [9] were used.
surgery and was identical to the first evaluation (PRE1),
except that the anamnesis was not repeated.
Functional Capacity
Postoperative Physiotherapeutic Evaluation (PO1)
Functional capacity was evaluated by the
Postoperative physiotherapeutic evaluation was 6MWT according to the recommendations of
performed 48 hours after the surgical procedure (PO1), the American Thoracic Society (ATS) [10]. The
obtaining only PImax and PEmax. test was performed at least 2 hours after meals.
The patients were asked to wear comfortable
clothing and footwear and to continue their
Hospital Discharge and Postoperative Day 30 usual medication. The test was administered in
(PO30) a hallway with a minimum length of 30 m and
free of other people. The patients were asked
PImax, PEmax, pulmonary function (FEV1, FVC, to walk at their own pace as far as possible for
FEV1/FVC), and functional capacity (6MWT) were 6 minutes. The patients received clarification
evaluated at discharge and on PO30. about possible cardiorespiratory changes that
could arise and were allowed to walk slowly or
to stop when necessary, returning to walk when
Measurement of Maximal Respiratory Pressures they felt able to start over. After 10 minutes, blood
pressure, heart rate, respiratory rate, SpO2, and
The maximal respiratory pressures were obtained sensation of dyspnea and fatigue were measured.
to evaluate respiratory muscle strength. For these The last two were evaluated by the modified Borg
measurements, the patient was seated and used a nose scale, which ranges from zero (no effort) to 10
clip. A properly calibrated analog manovacuometer (maximal effort). The subjects were encouraged
(ranging from 0 to ± 300 cmH2O) (GeRar, Sao Paulo, SP, to walk every minute using standard phrases. At
Brazil) was used for the pressure measurements. PImax the end of the test, the initially collected vital data
was measured from residual volume and PEmax from and the perception of dyspnea and fatigue were
total lung capacity as described by Neder et al. [8]. again evaluated. In addition, the distance walked
At least three measurements of each variable were by the patient was calculated. Two tests were
obtained, with a resting period of approximately 1 minute performed at a minimum resting interval of 30
between maneuvers. The maneuver was only considered minutes. The test was repeated to eliminate the
valid when the pressure was sustained for at least 2 effect of learning and to ensure reproducibility
seconds. If the highest value was observed in the third of the procedure.
maneuver, the measurement was repeated until the same
or a lower value was obtained, with a variation < 10% Control Group
between measurements.
The highest value of each variable (PImax and PEmax) Patients of CG were taught to perform the respiratory
was considered for analysis, given that it was not the value exercises (diaphragmatic and in three times) and
obtained in the last maneuver. These measurements were breathing-associated upper and lower limb exercises.
made weekly in the outpatient clinic. The subjects were asked to perform 10 repetitions of
each respiratory and limb exercise, 5 times per week. In
Spirometry addition, they received instructions about the importance
of pre- and postoperative physiotherapy and were
Spirometry was performed at HC-UFTM with a encouraged to remain active within their physical limits.
properly calibrated Master Screen-Pneumo apparatus

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 Evaluation of the effectiveness of preoperative outpatient pulmonary preparation in patients undergoing esophageal surgery
5

Written instructions in the form of explanatory Statistical Analysis

leaflets about the exercises that should be performed
at home were given to the patients. In addition, the The Kolmogorov-Smirnov test was used to determine
patients were asked to record on the exercise sheet whether the data were normally distributed. Parametric data
whether they had performed the exercise and whether were compared by the Student t-test and nonparametric
they had experienced some type of discomfort during data by the Wilcoxon test. Pearson’s and Spearman’s
their execution. correlation coefficients were calculated to evaluate
After the first preoperative evaluation, the patients correlations. Differences were considered significant when p
were asked to perform these exercises at home as < 0.05. Statistical analysis was performed using the Microsoft
instructed and returned to the outpatient clinic once Excel 2010, GraphPad Prism 5.0, and SPSS 16.0 programs.
a week until the date of hospital admission. During the
weekly return visits, the responsible researcher verified Results
whether the exercises had been performed correctly
and the instructions were reinforced. Table 1 shows the anthropometric characteristics
and risk factors (incidence of smoking and
alcohol consumption) of the groups in the first
Intervention Group physiotherapeutic evaluation.

Patients of IG received the same instructions as those

of CG, except for the addition of IMT. The Threshold IMT Table 1 - Anthropometric data and risk factors of patients
(Philips Respironics, NJ, USA) was used for training at an of the control and intervention groups obtained in
initial load of 60% PImax. The patients performed three the first preoperative evaluation (PRE1)
sets of 12 repetitions, 5 times per week. The load was Variables CG (n=10) IG (n = 12) p
adjusted weekly in the case of an increase in PImax in Anthropometric
order to maintain the load at 60% of PImax. In addition Age (years) 54.5 ± 9.9 53.3 ± 12.6 0.815
to the exercise leaflets, the patients received a Threshold Male, n (%) 4 (40.0) 7 (58.3) 0.392
IMT provided by HC-UFTM so that they could perform the
BMI (kg/m2) 23.1 ± 5.0 24.6 ± 4.8 0.479
intervention proposed at home. In this group, the patients
Risk factors
were also asked after the first evaluation to perform the
History of smoking, n (%) 0.728
exercises at home and returned to the outpatient clinic
once a week until the date of hospital admission. The Non-smoker 4 (40.0) 4 (33.3)
same researcher accompanied the patients of the two Ex-smoker 1 (10.0) 3 (25.0)
groups during the preoperative period. Smoker 5 (50.0) 5 (41.7)
The exercises were performed by patients of CG and Alcohol consumption, n (%) 3 (30.0) 4 (33.3) 1.00
IG during the preoperative period between the first
(PRE1) and second (PRE2) evaluation, i.e., 48 hours Note: Continuous variables are reported as mean ± standard deviation.
before the surgical procedure. CG = control group; IG = intervention group; BMI = body mass index.

Table 2 - Respiratory muscle strength, pulmonary function and functional capacity of the control and intervention groups in
the first and second physiotherapeutic evaluation, in the postoperative evaluations immediate after surgery and on
day 30, and at discharge
(To be continued)
Group PRE1 PRE2 PO1 Discharge PO30 p

Respiratory muscle strength

PImax (cmH2O) CG -76.0 ± 37.8 -74 ± 36 -35 ± 23 -60 ± 27 -81 ± 33 0.014
IG -90.0 ± 33.8 -103 ± 20 -42 ± 17 -57 ± 20 -86 ± 16

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 Cunha FMR, Borges MC, Fanan JMV, Oliveira PF, Volpe MS, Crema E.
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(Conclusion)

Group PRE1 PRE2 PO1 Discharge PO30 p

Respiratory muscle strength

PEmax (cmH2O) CG 97.0 ± 25.0 98 ± 32 68 ± 36 77 ± 30 99 ± 26 0.095
IG 110.8 ± 28.1 123 ± 22 58 ± 29 74 ± 28 108 ± 31
Pulmonary function
FEV1 CG 91.1 ± 15.0 91.1 ± 15.0 - 68.3 ± 16.9 86.1 ± 14.8 0.58
(% predicted) IG 88.8 ± 19.9 86.6 ± 19.3 - 60.7 ± 14.1 84.8 ± 10.1
FVC CG 99.2 ± 14.5 99.2 ± 14.5 - 71.2 ± 19.2 92.9 ± 15.1 0.561
(% predicted) IG 95.9 ± 14.7 95.4 ± 15.3 - 61.6 ± 14.3 88.0 ± 12.7
FEV1/FVC CG 74.9 ± 7.9 74.9 ± 7.9 - 78.8 ± 7.7 75.7 ± 7.8 0.499
IG 74.4 ± 11.3 73.4 ± 11.2 - 80.2 ± 8.9 78.9 ± 8.6
Functional capacity
6MWT CG 507.5 ± 83.7 486 ± 62 - 442 ± 75 515 ± 73 0.02
IG 499.4 ± 73.6 514 ± 85 - 362 ± 90 458 ± 59

Note: Continuous variables are reported as mean ± standard deviation. *p < 0.05. CG = control group; IG = intervention group; PRE1 and
PRE2 = first and second preoperative physiotherapeutic evaluation; PO1 = postoperative evaluation 48 hour after surgery; PO30 = evalu-
ation on postoperative day 30; PImax = maximal inspiratory pressure; PEmax = maximal expiratory pressure; FEV1 = forced expiratory
volume in the first second; FVC = forced vital capacity; 6MWT = 6-minute walk test.

Patients of IG exhibited a significant increase in these parameters was observed on PRE2, discharge and
PImax after preoperative training compared to CG (p PO30 when compared to PRE1, without a significant
= 0.014). PImax increased by 22% between PRE1 and difference between groups: FEV1 (% predicted, p = 0.58),
PRE2. A reduction of 3% in mean PImax was observed in FVC (% predicted, p = 0.561) and FEV1/FVC (p = 0.499).
IG and CG. On PO1, there was an important reduction of After intervention, patients of IG increased the
PImax in the two groups, which was more marked in IG (p distance walked in the 6MWT by 15 m, while a reduction
= 0.011; contrast analysis). A partial increase in PImax was of 22 m was observed in CG, but the difference was not
observed on the day of discharge in the two groups, but statistically significant (p = 0.166). The distance walked
recovery was greater in CG (p = 0.015; contrast analysis). in the 6MWT was reduced in the two groups on the
Full recovery of baseline values was found in both groups on day of discharge. However, when compared to PRE2,
PO30, but patients of IG did not reach the PImax achieved in the reduction was more important in IG compared to
PRE2, i.e., after IMT (p = 0.005; contrast analysis). CG (p = 0.02; contrast analysis). On PO30, the distance
PEmax showed a similar trend as PImax, increasing in walked increased in both groups (p = 0.02).
IG and practically remaining unchanged in CG after training; Pulmonary complications were observed in 40%
however, the difference was not significant (p = 0.095). of patients of CG and 35% of IG at some point between
On PO1, patients of the two group exhibited an important postoperative days 1 and 5. However, there was no
reduction in PEmax, which was more marked in IG (p = 0.007; significant difference between the two groups (p = 0.562).
contrast analysis). A partial increase in PEmax was observed Only one patient of IG developed pneumonia. The most
on the day of discharge in the two group, but recovery was frequent complications in the two groups were hypoxemia
greater in CG (p = 0.022; contrast analysis). Full recovery of (SpO2 ≤ 90% in ambient air) and productive cough.
baseline values was found on PO30 in both groups. Table 3 shows the duration of the surgical procedure
With respect to pulmonary function, a reduction in (min) and mechanical ventilation (min) and the length
of hospital stay after surgery (days).

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 Evaluation of the effectiveness of preoperative outpatient pulmonary preparation in patients undergoing esophageal surgery
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Table 3 - Duration of the surgical procedure and mechanical ventilation and length of hospital stay after surgery

Variables CG (n = 10) IG (n = 12) p

Duration of surgery (min)* 278 (230-334) 288 (239-434) 0.456
Duration of MV (min)* 225 (170-300) 325 (191-785) 0.123
Length of hospital stay (days)# 9.6 ± 5.1 8.5 ± 6.4 0.665
Note: *Median (IQ 25-75%); #mean ± standard deviation. CG = control group; IG = intervention group; MV = mechanical ventilation.

Discussion although the groups were homogenous before surgery,

the duration of surgery and mechanical ventilation was
The incidence of megaesophagus continues to be longer in IG. Another factor that might have compromised
high in Brazil because of its association with Chagas more satisfactory results after IMT is the important
disease. It is estimated that 5% to 8% of patients with nutritional deficit of these patients, who require a longer
Chagas disease develop megaesophagus [11]. Surgical period of training than that adopted in our study in
interventions in these patients are associated with order to exhibit a real gain in muscle strength [17]. The
complications during the immediate postoperative minimum period of IMT established in our study was
period as a result of the use of general anesthesia and shorter than that adopted in other studies [18, 19]. Our
the fact that organ manipulation is done close to the lungs. patients were asked to perform IMT 5 times per week for
Postoperative pulmonary complications in these patients a minimum period of 2 weeks (at least 10 sessions). We
include reduced pulmonary function and respiratory chose a period that could have benefits for the patients
muscle strength, diaphragm paralysis, pleural effusions, and, at the same time, was feasible within the routine
atelectasis, pneumonia, respiratory insufficiency, and outpatient care of the institution.
pulmonary embolism [12]. Esophagectomies (complete Kulkarni et al. [18] showed that preoperative IMT before
or partial resection of the esophagus) can lead to a major abdominal surgeries performed twice a day, 7 days
reduction in lung volume and ventilatory capacity of per week, for a minimum period of 2 weeks, attenuated the
about 40% and 60%, respectively, with consequent decline in PImax during the postoperative period compared
important pulmonary complications [13]. to other interventions. Morano et al. [19] found that
Preoperative physiotherapy establishes a link preoperative IMT performed 5 times per week, for 4 weeks,
with the patient, identifying the main risk factors for significantly increased maximal respiratory pressures, 6MWT
postoperative pulmonary complications, and prevents performance and FVC in patients undergoing lung cancer
and guides the physiotherapeutic techniques used for resection divided into two groups, a rehabilitation group
recovery [14]. Evidence indicates the need for preoperative (strength and endurance) and a pulmonary physiotherapy
physiotherapy in upper abdominal and thoracic surgeries, group (exercises for lung expansion).
including respiratory muscle training to prevent future Another important point is that the type of IMT used in
complications. This training was found to increase strength our study differed from that adopted in other clinical trials
and endurance of the diaphragm, with improvement in [20, 21]. Our patients performed IMT of high intensity (3
pulmonary function [15]. Kendall et al. [16] recommended sets of 12 repetitions at an initial load of 60% PImax), while
physiotherapy using maneuvers of sustained maximal IMT was performed at low intensity in the other studies,
inspirations with a linear load Threshold device to treat with the initial load ranging from 20% to 30% of PImax
postoperative pulmonary complications. maintained for 15-30 minutes. In the study of Morano et
In the present study, preoperative IMT resulted al. [19], the load was increased progressively until reaching
in a significant increase in PImax, but this increase in 60% of PImax. However, we do not believe that the type
inspiratory muscle strength did not provide satisfactory of training performed has contributed to our results since
PImax levels during the postoperative period and did not evidence indicates that high-intensity IMT is more effective
influence recovery of the patients. Patients of IG exhibited than low-intensity training.
a greater reduction in maximal respiratory pressures on No significant alterations were observed in the
PO2 and in the distance walked in the 6 MWT on the day spirometry variables. However, these data agree with
of discharge when compared to the reduction observed another study that reported that, although spirometry
in CG. These results can be explained by different factors, is an important technique to determine the degree

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 Cunha FMR, Borges MC, Fanan JMV, Oliveira PF, Volpe MS, Crema E.
8

of obstruction, it has not been effective in detecting with those reported by Weiner et al. [29] who studied
differences after rehabilitation programs [22]. patients undergoing myocardial revascularization
The surgical incision can directly affect the integrity of surgery. The patients were divided into a control
respiratory muscles (muscle tissue and/or innervation) group and a treatment group that was submitted to
and consequently compromise their function. In addition, preoperative IMT for 2 to 4 weeks at an initial load of
these patients are likely to experience more pain, which 15% PImax, with a load increment of 5% every session
may contribute to inspiratory muscle dysfunction. The until reaching 60% of PImax. The authors found a
adoption of a superficial respiratory pattern, which is significance increase in inspiratory muscle strength and
characterized by low tidal volumes and a high respiratory endurance, but there was no significant difference in the
rate, also contributes to the maintenance or greater incidence of postoperative pulmonary complications
reduction in lung volumes during the postoperative compared to the control group.
period. The type of incision can also alter the configuration A systematic review of the effects of preoperative
of the rib cage and influence the occurrence of atelectasis, training interventions before thoracic and abdominal
events that decrease complacency of the respiratory surgeries showed that most articles on preoperative
system, increasing respiratory work and reducing the IMT involve patients undergoing heart surgeries. The
mechanical effectiveness of the respiratory muscles [23, authors concluded that there is moderate evidence
24]. In a cohort study, Canet et al. [25] evaluated 2,464 that IMT increases muscle resistance and low evidence
surgical patients to identify independent predictors of that it increases muscle strength and lung volume and
postoperative pulmonary complications. The authors decreases postoperative pulmonary complications and
found that patients with the surgical incision in the the length of hospital stay [30].
upper abdomen were 4.4 times more likely to develop
pulmonary complications than patients with incisions
at peripheral sites. If located in the chest, the chance Conclusion
increased to 11.4.
Regarding the 6MWT, an increase in the distance The IMT performed in our study improved
walked was observed in IG after the intervention, but inspiratory muscle strength but did not influence the
the result was not significant (p = 0.166). Morano et postoperative evolution of pulmonary function or
al. [19] found significant improvement (p = 0,020) of functional capacity in patients undergoing esophageal
the distance walked in the 6 MWT after 4 weeks of surgeries. Further studies investigating preoperative
preoperative IMT in patients undergoing lung cancer IMT using the Threshold device in patients undergoing
resection. In the study of Winkelmann et al. [26], patients esophageal surgeries that include a larger number of
with heart failure and respiratory muscle weakness subjects and adopt a period of training longer than
were divided into a group submitted to aerobic training 2 weeks are needed in order to more accurately
on a cycle ergometer and a group undergoing the same determine whether preoperative IMT reduces the rate
training combined with IMT at a load of 30% PImax for of postoperative pulmonary complications.
30 minutes per day. A significant difference in 6MWT
values was observed for the group submitted only to
aerobic training (p < 0.001). References
Since IMT did not attenuate he reduction of PImax
in IG compared to CG during the early postoperative 1. Ribeiro AR, Lima L, Almeida LA, Monteiro J, Moreno
period and did not influence the behavior of the other CJG, Nascimento JD, et al. Biological and molecular
variables, it is not surprising that there was no significant characterization of Trypanosoma cruzi strains from four
difference in the frequency of pulmonary complications states of Brazil. Am J Trop Med Hyg. 2018;98(2):453-63.
between the two groups. However, the incidence of
2. Nava A, Shimabukuro JS, Chmura AA, Luz SLB. The
clinically significant complications in the two groups
Impact of global environmental changes on infectious
(35% versus 40% in IG and CG, respectively) was similar
disease emergence with a focus on risks for Brazil. ILAR
to that reported in the recent literature [27, 28].
J. 2017. doi: 10.1093/ilar/ilx034.
In the present study, the two groups studied did
not differ in the frequency of pulmonary complications
between postoperative days 1 and 5. These results agree

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Recebido em 23/01/2018
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Recibido en 23/01/2018
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Ann Thorac Surg. 2011;91(5):1494-1500. Aprovado em 26/02/2018
Aprobado en 26/02/2018

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