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EFFECTS OF PRE OPERATIVE EDUCATION AND VENTILATORY EXERCISE TRAINING IN REDUCING ANXIETY AND IMPROVEMENT IN RECOVERY AMONG CARDIAC PATIENTS

DR.CHIRAG PURBIA, Assistant Professor,

Geetanjali college of Physiotherapy, Udaipur, Rajasthan

OBJECTIVE:

To evaluate the effects of pre operative education and ventilatory exercise training in reducing anxiety and improvement in recovery among cardiac patients.

BACKGROUND:

Patients awaiting cardiac surgery typically experience physical and psychological stress. Although

there is evidence that preoperative education can improve postoperative outcomes among

general surgical patients, less is known about preoperative education for patients

undergoing cardiac surgery. Physiotherapists play an important role in the preparation and

rehabilitation of patients who had undergone surgical procedures. In the present study, the

effects of pre operative education and ventilatory exercise training were observed to know

the effectiveness in reducing anxiety and improvement in recovery among patients

undergoing cardiac surgery.

METHODOLOGY:

This study includes 100 subjects both male and female undergoing elective cardiac

surgery of age 18-60 years who were eligible as per the inclusion criteria. Pre- participation

questionnaire along with the consent form was given to the subjects to fulfill criteria for

selection. Subjects were allocated physiotherapy instructions and ventilatory exercise

training pre operatively. The primary outcome was change in anxiety which was measured

by BAI (Beck Anxiety Inventory) pre operatively before and after education and training and

4 days post operatively. Secondary outcomes were pain and SPO2 which were measured by

VAS (Visual Analogue Scale) and pulse oxymetry respectively.

RESULTS:

Results showed that anxiety score after pre operative instructions and ventilatory

exercise training exercise was significantly higher (p<0.01) in males as compared to females.

There was a significant decrease in score of anxiety pre and post operatively after

physiotherapy instructions and ventilatory exercise training (p<0.01) and there was also a

significant reduction in VAS score (p<0.01) whereas SPO2 was increased significantly

(p<0.01). Thus it showed that pre operative education and ventilatory exercise training is

effective in reducing anxiety and improves recovery among patients undergoing cardiac

surgery.

CONCLUSION:

This study provides empirical support for the hypothesis that a pre operative

education intervention involving counseling, verbal explanation and ventilatory training are

effective in reducing anxiety and pain among patients undergoing cardiac surgery. This study

not only have important implications for effective strategies to control patient’s elevated

anxiety in anticipation of cardiac surgery, but also help make recommendations for quality

improvement of pre operative education in practice.

KEY WORDS: Pre operative education, cardiac surgery, anxiety, ventilatory training.

INTRODUCTION

Coronary artery disease is the leading cause of morbidity and mortality worldwide. For more than 15 years,

WHO has been sounding an alarm on the rapidly rising burden of cardiovascular disorders.

The reported prevalence of coronary artery disease (CAD) in adult surveys has risen 4-fold

over the last 40 years to a present level of around 10%.8

The burden of CVD is projected to be the highest in India by the year 2020, as compared to other

countries.9 In the WHO-PREMISE study, the proportion of CHD among patients less than 50

years of age, was highest in India (22.6% in males and 3% in females).10 In the Million Death

Study(2009), the authors determined that CVD are the leading cause of death (20.3% in

males and 16.9% in females) among Indian adults (age 25-69 years). 11

Cardiovascular diseases, especially coronary heart disease (CHD), are epidemic in India. The Registrar

General of India reported that CHD led to 17% of total deaths and 26% of adult deaths in

2001-2003, which increased to 23% of total and 32% of adult deaths in 2010-2013.8

Cardiovascular disease is the leading global cause of death, accounting for more than 17.3 million deaths

per year, a number that is expected to grow to more than 23.6 million by 2030.12

In 2013, cardiovascular deaths represented 31 percent of all global deaths, with 80 percent of those deaths

taking place in lower and middle income countries. Nearly 801,000 people in the U.S. died

from heart disease, and other cardiovascular diseases in 2013. That’s about one of every

three deaths in America. About 2,200 Americans die each day from these diseases, one

every 40 seconds.12

Cardiac surgery is a procedure performed in patients with cardiovascular disease. After cardiac surgery,

various complications that will require specific care, especially in the respiratory system, can

be observed. These complications can lengthen the hospital stay of patients, causing

increased hospital costs and becoming an important cause of morbidity and mortality.14

The coronary artery bypass grafting presents satisfactory results, however, is has the pain caused by the

nociceptive stimulus from sternotomy as an important cause of mortality and morbidity in

the postoperative period, which leads less effectiveness of cough, by adopting a rapid and

superficial breathing, and can cause pulmonary complications such as atelectasis.15

Nevertheless, patients who had undergone heart surgery may suffer psychological disorders such as

anxiety, which is hardly noticeable in the pre-operative, and it may go unnoticed by the

medical team, since often such disorder is related to physical illnesses.16 These can

exacerbate symptoms of existing cardiovascular disease, adversely affect physiological

parameters before and during anaesthesia, and can result in prolonged recovery .25,26

Cardiac patients with a high level of anxiety can experience physical symptoms including headache,

dizziness, nausea, muscle weakness, fatigue, sweating, and difficulty falling asleep, or even

more intense symptoms such as chest pain, palpitations, shortness of breath. Chest pain is a

common symptom of anxiety and may take form of a sharp pain or a feeling of visceral

tightness.29

Decreases in essential parameters of vital capacity, functional residual capacity, and forced expiratory

volume may directly contribute to atelectasis, which can contribute to postoperative

pulmonary complications. Pulmonary function is further compromised by hypoventilation,

decreased mucous clearance, decreased respiratory muscle function, increased work of

breathing, and hypoxia—all ramifications of the surgical procedure. 36Additionally, walking

ability is limited after CABG surgery.37

Breathing exercises and ventilatory training are fundamental interventions for the prevention and

management of post operative complications (PPC’S). Breathing exercises and ventilatory

training includes diaphragmatic breathing, segmental breathing, inspiratory resistance

training, glossopharyngeal breathing, breathing techniques for the relief of dyspnea during

exertion.39

Chest mobilization exercises combine active movements of the trunk or extremities with deep breathing.

They are designed to maintain or improve mobility of the chest wall, trunk and shoulder

girdles when it affects ventilation or postural alignment.39

Airway clearance is an important part of management of patients. An effective cough is necessary to

eliminate respiratory obstructions and keep the lungs clear. ACBT (active cycle of breathing

technique) can be used to stimulate a stronger cough, improving clearance of secretions.

Postural drainage, another intervention for airway clearance, is a means of mobilizing

secretions in one or more lung segments to the central airways and cleared by coughing or

endotracheal suctioning.39,40

Incentive spirometry is a form of ventilatory training that emphasizes sustained maximum inspirations.39

Pre-operative education is defined as providing the patient with health related information, psychosocial

support and the opportunity to learn specific skills in preparation for surgery. Pre-operative

program might include a number of components and inclusion of family members, teaching

of specific skills.4

Physiotherapists play an important role in the preparation and rehabilitation of patients who had

undergone surgical procedures. In addition to having a large arsenal of techniques, the,

physiotherapist has been one of the professionals that more time is next to the patients. As

such, it is suggested that time spent is better spent, by favoring professionals to clarify the

doubts of the patients and guide them to the new situations that they will have to face.5

Early mobilization, positioning, breathing exercises and techniques for bronchial hygiene are the usual

techniques utilized.1

METHODOLOGY:

A total 100 number of both males and females were selected or this study

undergoing cardiac surgery was taken from CTVS ICU Geetanjali Medical College and

Hospital (GMCH). Based on assessment, interview and questionnaire subjects were excluded

of Acute and Chronic Asthma, Previous Cardiac Surgical history, Unstable vitals, Cardiac

pacemaker, Shortness of breath more than grade 3or 4, Pregnancy, Unstable angina

pectoris, Psychosomatic disorders. information and demonstrations of ventilatory exercises

was performed to the patients individually, for the improvement of pulmonary ventilation

and bronchial hygiene. Explanation to the patients was given regarding sternotomy and the

importance of maintaining an appropriate pulmonary ventilation and cough, so avoiding

possible pulmonary complications. Each patient received on written, physiotherapeutic

guidelines on ventilatory exercise and ventilatory exercise training that could be performed

after surgery. After guidance, anxiety was evaluated pre and post operatively by Beck

Anxiety Inventory. When it was necessary, the ventilatory exercises were reminded to

patients. The primary outcome was change in anxiety which was measured by BAI (Beck

Anxiety Inventory) pre operatively before and after education and training and 4 days post

operatively. Secondary outcomes were pain and SPO2 which were measured by VAS (Visual

Analogue Scale) and pulse oxymetry respectively.

RESULTS:-

Pair Variables Mean SD SEm T Df P

1

Pre operatively BAI at the time

of admission and BAI after

physiotherapy instructions

19.887 2.753 0.350 56.887 61 0.000

2

Pre operatively BAI after

physiotherapy instructions and

BAI post operatively

12.387 2.836 0.360 34.389 61 0.000

3

Pre operative VAS and post

operative VAS

3.790 0.813 0.103 36.730 61 0.000

4

Pre operative SPO2 and post

operative SPO2

-5.597 2.854 0.362 -5.440 61 0.000

DISCUSSION:-

According to the results of the study, preoperative education reduced the anxiety of patients undergoing

cardiac surgery and had an effect on postoperative complications. This finding is consistent

with that reached by Guo Ping, who found a significant reduction in post operative anxiety

after pre operative education of patients who underwent CABG. Only one study by

BAI VAS SPO2 Pre 42.28 7.69 92.45 Post 21.93 Post OP 9.93 3.9 97.75 0

20

40

60

80

100

120

Pre Post Post OP

Deyirmenjian M showed that pre operative education increased the post operative anxiety

of patients. This is probably due to the difference in the timing and the manner of education

delivery. . Heather et al. applied a protocol of preoperative intervention in patients

undergoing coronary artery bypass grafting by a multidisciplinary team of cardiologists,

surgeons and physiotherapists. There was a reduction of one week in hospital stay in the

group receiving the intervention, as well as improvement in quality of life of these patients,

which lasted for 6 months. However, mortality rates and levels of anxiety both

preoperatively and postoperatively did not differ between groups.

Physiotherapists play an important role in the preparation and rehabilitation of patients who had

undergone surgical procedures. In addition to having a large arsenal of techniques, the

physiotherapist, notoriously, has been one of the professionals that more time is next to the

patients. As such, it is suggested that time spent is better spent, by favoring professionals to

clarify the doubts of the patients and guide them to the new situations that they will have to

face. Some symptoms reported by anxious patients, such as tachycardia, tachypnea, and

high systemic blood pressure, may be mistaken as part of the presentation developed by

coronary artery disease. Conceição et al. reported that the measurement of blood pressure

and heart rate are not good parameters to measure the patient’s anxiety level, requiring the

assessment of the disorder by means of validated scales such as the Beck anxiety Inventory.

According Trame et al. , the Inventory is widely used because of its cost-effectiveness, ease

of application and interpretation.

In our study, results showed that except anxiety score after counseling which was significantly higher in

males as compared to females (p<0.01) , there was no difference for rest of the parameters.

Score of anxiety and pain has been reduced after pre operative education and ventilatory

training significantly (p<0.01). Score of SPO2 increased significantly. The correlation was

significantly positive for anxiety and pain pre and post operatively.

CONCLUSION:-

This study provides empirical support for the hypothesis that a pre operative education intervention

involving counseling, verbal explanation and ventilatory training are effective in reducing

anxiety and pain among patients undergoing cardiac surgery. This study not only have

important implications for effective strategies to control patient’s elevated anxiety in

anticipation of cardiac surgery, but also help make recommendations for quality

improvement of pre operative education in practice.

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