The efficacy of pulmonary physiotherapy in bariatric surgery: a comparative study

Authors

Abstract

AimIn this study, we aimed to compare the pulmonary functions in patients who have undergone laparoscopic sleeve gastrectomy (LSG) with and without pulmonary physiotherapy (PP).
MethodsParticipants were randomized and separated into two groups of 61 patients each. In the first group, PP and mobilization were advised, and in the second group, ony mobilization was advised and pursued by medicians. The treatment protocol began on the postoperative first day and continued until the postoperative first week. The parameters assessed were pulmonary functions, a 6-minute walk test (6MWT) for lung capacity.
ResultsThe average age of the participants was 42 ± 3.16 years. The outcomes of the parameters were significantly different in patients who received PP compared with the control group. Significant healing was revealed, as well as an improvement in all the parameters of participants who underwent PP compared with the control group (p=0.017*,0.012*,0.077,0.027).
ConclusionIn patients with morbid obesity who have undergone sleeve gastrectomy, with the help of pulmonary physiotherapy, respiratory functions improved, oxygen saturation increased, functional capacity increased and they were discharged early.

Keywords

Introduction

Morbid obesity is a common disease in all developed countries, and the definitive solution is primarily surgery as the only option for patients who have not benefited from medical and supportive treatment. LSG, which has become almost the first step in bariatric surgery, also plays a significant role. After the bariatric surgery, patients lose weight, daily activities can be performed more effectively, and intra-abdominal pressure on the lung cavity decreases.
Pulmonary physiotherapy (PP) plays a significant role in the prevention of postoperative complications of bariatric surgery. Functional lung exercise decreased the length of stay in the hospital, and also possible complications such as atelectasis, pneumonia of pulmonary physiotherapy modalities were suggested.¹
Furthermore, pulmonary physiotherapy ensures adequate ventilation in the lungs, limited motion and increased muscle tone, and recommendations to contribute to good posture, and better rehabilitation program improve the patient’s quality of life.^2,3,4 In this study, we aimed to compare the pulmonary functions in patients who have undergone laparoscopic sleeve gastrectomy (LSG) with and without PP.

Materials and Methods

Pulmonary outcomes of 122 patients who underwent LSG in a tertiary bariatric clinic were evaluated retrospectively. The Local Ethics Committee approved this retrospective research (Date: 2020/8, Decision No: 173). The necessary consultations (endocrinologist, psychiatrist, pulmonologist, nutritionist) were made for the patients who applied before the operation. BMI values of all patients were > 40 kg/m2. Bariatric procedures were also performed by an experienced bariatric surgeon team.
Study ProtocolTrial DesignPulmonary physiotherapy was performed on Group 1 patients who have undergone sleeve gastrectomy for 7 days. The therapy process began from the first day to the 7th day. All exercises were performed by a physiotherapist in the clinic until the discharge period.
In the preoperative and postoperative periods, the following parameters were evaluated: oxygen saturation, respiratory function test, a 6-min walk test for functional capacity. Pre- and post-test evaluations were performed by a physician in the field of the study. The physiotherapy protocol included postural drainage, breathing exercises, and coughing techniques. All pulmonary exercises were repeated twice a day for a total of 8 times.
Participants were mobilized as immediate as possible, they walked 45 minutes along the aisle on the second day.
ParticipantsOne hundred twenty-two patients who have undergone LSG were separated into two groups of 61 patients each. The presence of chronic respiratory disease, alcohol, smoking, and drug dependence were added as exclusion criteria.
Pulmonary FunctionsLung capacities were assessed utilizing a spirometer (Model 2010, Medizintechnik AG, Zurich, Switzerland) according to the Thoracic Society guidelines. Vital capacity, forced vital capacity, and maximal voluntary ventilation performances were used. The highest values of forced vital capacity (FVC), (FEV1), FEV1/FVC ratio, peak exhaling flow (PEF), vital capacity (VC) were determined.
Minute Walk TestParticipants were asked to walk for 6 min along the clinic corridor. Standardized suggestions were given in every 60 minutes. The maximum distance, which was performed at the end of the application was recorded.⁵
Ethical ApprovalThis study was approved by the Local Ethics Committee of Selcuk University (Date: 22.04.2020, Decision No: 173).
Statistical AnalysisData were analyzed using IBM SPSS Statistics 26 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics were used to describe the basic characteristics. T-Tests were performed for indicating differences between the groups. p=0.05 was accepted as significant for all statistical levels.

Results

A total of 80 females and 42 males were included. The average age was 42.3 years, and body mass index (BMI) was 43.1 kg/m2, however there was no significant difference determined among the study groups. Each group included 61 patients (Table 1). Pulmonary functions of the participants after the procedure were assessed, and all values in the pulmonary physiotherapy group were found to be elevated, on the other hand, VC, TV, and FEV1/FVC outcomes were determined as statistically significant healing in pulmonary physiotherapy group (p<0.05) (Table 1). The 6-minute walking test scores demonstrated a statistically significant increase after the physiotherapy process (p<0.05). Furthermore, only 6-minute walking test was detected as significant elevation (Table 2).

Discussion

Morbid obesity disease is a common health problem all over the world, furthermore, this disease affects lung compliance worse than in the non-obese population. Bariatric Surgery is one of the most effective treatments for morbid obesity and has been demonstrated to positively affect pulmonary functions. Although there are some studies about pulmonary problems that may establish after a bariatric process, there are few studies about pulmonary physiotherapy enforcements for the early recovery time.^4,6,7,8
The aim of this research is to demonstrate that postoperative pulmonary physiotherapy resulted in increased respiratory function, saturated oxygen ratio, and functional capacity in participants after bariatric surgery. In addition, morbid obesity negatively affects lung function and decreases the contraction force of the pulmonary muscles.
Brovman et al. showed significant variation in TV in morbidly obese patients in the postoperative period. They also found significant improvement in pulmonary functions due to weight loss after the bariatric surgery and a reduction in pressure on the lung capacity. Pulmonary physiotherapy is a treatment modality especially in patients with morbid obesity. The real purpose of pulmonary physiotherapy is to rehabilitate the strength of exercise.^9,10
Lung capacity volumes were decreased after the surgical process, therefore, due to this process participants should force their bodies to walk as far as possible to prevent complications such as atelectasis, thromboembolism etc. In another study by Van Limmen et al., they found that FVC, FEV1 outcomes decreased after the laparotomy, besides, Borges-Santos et al. found a decline in pulmonary functions after the bariatric process on weight.^11,12
Because of this, pulmonary physiotherapy postoperatively is so important. Abdominal surgical process has demonstrated that expiratory reserve volume is reduced in morbidly obese patients compared to non-obese participants. The most common complication after the bariatric process is atelectasis, which is also determined in nearly 40% of the population. For this reason, pulmonary physiotherapy is the most significant therapeutic approach for the prevention of possible pulmonary complications.^13,1 Pouwels et al. showed that participants who have taken pulmonary treatment had elevated inspiratory muscle strength and maximal inspiratory pressure (MIP) on postoperative 3rd and 6th months and achieved greater improvement than the control group.¹⁴
Furthermore, a study by Umemura et al. found that patients who have undergone bariatric procedure supported with pulmonary physiotherapy experienced greater postoperative healing than those who have not undergone.¹⁵ Tomich et al. reported that in obese women, breathing exercises are particularly effective with the volume-oriented device, and this leads to increased inspiration volume and reduced possible complications after bariatric surgery.¹⁶
In the present study, it was shown that the participants who underwent pulmonary physiotherapy demonstrated an increase in pulmonary functions after the surgical process. Furthermore pulmonary rehabilitation aid to patients for decreasing the complications such as atelectasis and also pneumonia. Besides that 6MWT is utilized for evaluating the differences in lung capacity after the pulmonary rehabilitation process. Desy Salvadego et al. reported that respiratory muscle endurance training (RMET) with body mass reduction program in obese participants resulted in a reduction in the O2 cost of cycling and perceived exertion during constant heavy-intensity exercise, and also this exercise program strengthened respiratory muscles. Furthermore, the meta-analysis by Li et al., have analyzed 11 RCTs and demonstrated an important improvement in the 6MWT post-intervention distance.¹⁸ The 6MWT is widely utilized for evaluating walking capacity.^{19,20,21,22,23} This is a convenient and safe process to evaluate the functional capacity of morbidly obese patients who have undergone the bariatric process.^24,25
Present study outcomes have shown that participants who underwent pulmonary physiotherapy were determined as 51% recovery in a 6-min walking distance. According to these outcomes, it has been found that the exercise volume of patients who have undergone surgery, particularly bariatric surgery, can be improved by pulmonary physiotherapy.
In the literature review, our study is one of the rare studies, which evaluate the lung capacity and exercise performance by applying the pulmonary physiotherapy.
There are also some limitations in the present research. First, the follow-up period is short and patients were not called again for follow-up in the first year. Secondly, high-resolution computed tomography was not utilized to show possible pulmonary complications.

Conclusion

As a conclusion of this research, pulmonary physiotherapy, which is performed on morbid obese participants in the postoperative period has improved lung functions, oxygen saturation and also functional capacity in those who have undergone bariatric surgery.

Declarations

References

1. Forti E, Ike D, Barbalho-Moulim M, Rasera I Jr, Costa D. Effects of chest physiotherapy on the respiratory function of postoperative gastroplasty patients. Clinics (Sao Paulo). 2009;64(7):683-689. doi:10.1590/s1807-59322009000700013
   Article PubMed Google Scholar
2. Khair RM, Nwaneri C, Damico RL, Kolb T, Hassoun PM, Mathai SC. The minimal important difference in Borg dyspnea score in pulmonary arterial hypertension. Ann Am Thorac Soc. 2016;13(6):842-849. doi:10.1513/annalsats.201512-824oc
   Article PubMed Google Scholar
3. Hockele LF, Sachet Affonso JV, Rossi D, Eibel B. Pulmonary and functional rehabilitation improves functional capacity, pulmonary function, and respiratory muscle strength in post COVID-19 patients: pilot clinical trial. Int J Environ Res Public Health. 2022;19(22):14899. doi:10.3390/ijerph192214899
   Article PubMed Google Scholar
4. Küçükdeveci AA, McKenna SP, Kutlay S, Gürsel Y, Whalley D, Arasil T. The development and psychometric assessment of the Turkish version of the Nottingham Health Profile. Int J Rehabil Res. 2000;23(1):31-38.
   PubMed Google Scholar
5. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-117. doi:10.1164/ajrccm.166.1.at1102
   Article PubMed Google Scholar
6. Verbanck S, van Muylem A, Schuermans D, Bautmans I, Thompson I, Vincken W. Transfer factor, lung volumes, resistance, and ventilation distribution in healthy adults. Eur Respir J. 2016;47(1):166-176. doi:10.1183/13993003.00695-2015
   Article PubMed Google Scholar
7. Piskin O, Altinsoy B, Cimencan M, et al. The effect of bariatric anaesthesia on postoperative pulmonary functions. J Pak Med Assoc. 2017;67(4):561-567.
   PubMed Google Scholar
8. de Oliveira JJJ, de Freitas ACT, de Almeida AA. Postoperative effect of physical therapy related to functional capacity and respiratory muscle strength in patients submitted to bariatric surgery. Arq Bras Cir Dig. 2016;29(suppl 1):43-47. doi:10.1590/0102-6720201600s10012
   Article PubMed Google Scholar
9. Brovman EY, Foley CA, Shen AH, Whang EE, Urman RD. Intraoperative ventilation patterns in morbidly obese patients undergoing laparoscopic bariatric surgery. J Laparoendosc Adv Surg Tech A. 2018;28(12):1463-1470. doi:10.1089/lap.2018.0297
   Article PubMed Google Scholar
10. Vagvolgyi A, Rozgonyi Z, Kerti M, Agatho G, Vadasz P, Varga J. Effectiveness of pulmonary rehabilitation and correlations between functional parameters, extent of thoracic surgery, and severity of postoperative complications: randomized clinical trial. J Thorac Dis. 2018;10(6):3519-3531. doi:10.21037/jtd.2018.05.202
    Article PubMed Google Scholar
11. Van Limmen JG, Szegedi LL. Peri-operative spirometry: tool or gadget? Acta Anaesthesiol Belg. 2008;59(4):273-282.
    PubMed Google Scholar
12. Borges-Santos E, Genz IC, Longo AF, et al. Pulmonary function, respiratory muscle strength, and quality of life in patients submitted to elective thoracotomies. Rev Col Bras Cir. 2012;39(1):4-9.
    PubMed Google Scholar
13. Baltieri L, Santos LA, Rasera-Junior I, de Lima Montebelo MI, Pazzianotto-Forti EM. Use of positive pressure in pre- and intraoperative periods of bariatric surgery and its effect on the time of extubation. Rev Bras Anestesiol. 2015;65(2):130-135.
    PubMed Google Scholar
14. Franco AM, Torres FCC, Simin ISL, Morales D, Rodrigues AJ. Assessment of noninvasive ventilation with two levels of positive airway pressure in patients after cardiac surgery. Rev Bras Cir Cardiovasc. 2011;26(4):582-590.
    PubMed Google Scholar
15. Umemura A, Sasaki A, Nikai H, et al. Improvements of lung volumes and respiratory symptoms after weight loss through laparoscopic sleeve gastrectomy. Langenbecks Arch Surg. 2022;407(7):2747-2754. doi:10.1007/s00423-022-02549-x
    Article PubMed Google Scholar
16. Tomich GM, França DC, Diniz MT, Britto RR, Sampaio RF, Parreira VF. Effects of breathing exercises on breathing pattern and thoracoabdominal motion after gastroplasty. J Bras Pneumol. 2010;36(2):197-204. doi:10.1590/s1806-37132010000200007
    Article PubMed Google Scholar
17. Jenkins S. 6-minute walk test in patients with COPD: clinical applications in pulmonary rehabilitation. Physiotherapy. 2007;93(3):175-182. doi:10.1016/j.physio.2007.02.001
    Article PubMed Google Scholar
18. Li N, Li P, Lu Y, et al. Effects of resistance training on exercise capacity in elderly patients with chronic obstructive pulmonary disease: a meta-analysis and systematic review. Aging Clin Exp Res. 2020;32(10):1911-1922. doi:10.1007/s40520-019-01339-8
    Article PubMed Google Scholar
19. Salvadego D, Sartorio A, Agosti F, et al. Respiratory muscle endurance training reduces the O2 cost of cycling and perceived exertion in obese adolescents. Am J Physiol Regul Integr Comp Physiol. 2017;313(4).
    PubMed Google Scholar
20. van Huisstede A, Biter LU, Luitwieler R, Cabezas MC, Mannaerts G, Birnie E, et al. Pulmonary function testing and complications of laparoscopic bariatric surgery. Obes Surg. 2013;23(10):1596-1603. doi:10.1007/s11695-013-0928-9
    Article PubMed Google Scholar
21. Veloso APLR, Cusmanich KG. Evaluation of the thoracoabdominal mobility of obese subjects in pre-bariatric surgery. Arq Bras Cir Dig. 2016;29(suppl 1):39-42. doi:10.1590/0102-6720201600s10011
    Article PubMed Google Scholar
22. Flansbjer UB, Holmback AM, Downham D, Patten C, Lexell J. Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005;37(2):75-82. doi:10.1080/16501970410017215
    Article PubMed Google Scholar
23. Meys R, Janssen SMJ, Franssen FME, et al. Test-retest reliability, construct validity, and determinants of 6-minute walk test performance in adult patients with asthma. Pulmonology. 2023;29(6):486-494. doi:10.1016/j.pulmoe.2022.10.011
    Article PubMed Google Scholar
24. Rocha MRS, Souza S, Costa CM, et al. Airway positive pressure vs exercises with inspiratory loading focused on pulmonary and respiratory muscular functions in the postoperative period of bariatric surgery. Arq Bras Cir Dig. 2018;31(2). doi:10.1590/0102-672020180001e1363
    Article PubMed Google Scholar
25. Loréns J, Rovira L, Ballester M, et al. Preoperative inspiratory muscular training to prevent postoperative hypoxemia in morbidly obese patients undergoing laparoscopic bariatric surgery: a randomized clinical trial. Obes Surg. 2015;25(6):1003-1009.
    PubMed Google Scholar

About This Article

Received:

November 28, 2022

Accepted:

February 2, 2023

Published Online:

February 11, 2023

Printed:

May 1, 2023