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Review
. 2015 Oct 5;2015(10):CD010356.
doi: 10.1002/14651858.CD010356.pub2.

Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery

Morihiro Katsura  1 , Akira Kuriyama, Taro Takeshima, Shunichi Fukuhara, Toshi A Furukawa
Affiliations
Review

Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery

Morihiro Katsura et al. Cochrane Database Syst Rev. .

Abstract

Background: Postoperative pulmonary complications (PPCs) have an impact on the recovery of adults after surgery. It is therefore important to establish whether preoperative respiratory rehabilitation can decrease the risk of PPCs and to identify adults who might benefit from respiratory rehabilitation.

Objectives: Our primary objective was to assess the effectiveness of preoperative inspiratory muscle training (IMT) on PPCs in adults undergoing cardiac or major abdominal surgery. We looked at all-cause mortality and adverse events.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE (1966 to October 2014), EMBASE (1980 to October 2014), CINAHL (1982 to October 2014), LILACS (1982 to October 2014), and ISI Web of Science (1985 to October 2014). We did not impose any language restrictions.

Selection criteria: We included randomized controlled trials that compared preoperative IMT and usual preoperative care for adults undergoing cardiac or major abdominal surgery.

Data collection and analysis: Two or more review authors independently identified studies, assessed trial quality, and extracted data. We extracted the following information: study characteristics, participant characteristics, intervention details, and outcome measures. We contacted study authors for additional information in order to identify any unpublished data.

Main results: We included 12 trials with 695 participants; five trials included participants awaiting elective cardiac surgery and seven trials included participants awaiting elective major abdominal surgery. All trials contained at least one domain judged to be at high or unclear risk of bias. Of greatest concern was the risk of bias associated with inadequate blinding, as it was impossible to blind participants due to the nature of the study designs. We could pool postoperative atelectasis in seven trials (443 participants) and postoperative pneumonia in 11 trials (675 participants) in a meta-analysis. Preoperative IMT was associated with a reduction of postoperative atelectasis and pneumonia, compared with usual care or non-exercise intervention (respectively; risk ratio (RR) 0.53, 95% confidence interval (CI) 0.34 to 0.82 and RR 0.45, 95% CI 0.26 to 0.77). We could pool all-cause mortality within postoperative period in seven trials (431 participants) in a meta-analysis. However, the effect of IMT on all-cause postoperative mortality is uncertain (RR 0.40, 95% CI 0.04 to 4.23). Eight trials reported the incidence of adverse events caused by IMT. All of these trials reported that there were no adverse events in both groups. We could pool the mean duration of hospital stay in six trials (424 participants) in a meta-analysis. Preoperative IMT was associated with reduced length of hospital stay (MD -1.33, 95% CI -2.53 to -0.13). According to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group guidelines for evaluating the impact of healthcare interventions, the overall quality of studies for the incidence of pneumonia was moderate, whereas the overall quality of studies for the incidence of atelectasis, all-cause postoperative death, adverse events, and duration of hospital stay was low or very low.

Authors' conclusions: We found evidence that preoperative IMT was associated with a reduction of postoperative atelectasis, pneumonia, and duration of hospital stay in adults undergoing cardiac and major abdominal surgery. The potential for overestimation of treatment effect due to lack of adequate blinding, small-study effects, and publication bias needs to be considered when interpreting the present findings.

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Conflict of interest statement

Morihiro Katsura: None known.

Akira Kuriyama: None known.

Taro Takeshima: None known.

Shunichi Fukuhara: None known.

Toshi A Furukawa has received lecture fees from Eli Lilly, Meiji, Mochida, MSD, Pfizer, and Mitsubishi Tanabe, and consultancy fees from Sekisui and Takeda Science Foundation. He is diplomate of the Academy of Cognitive Therapy. He has received royalties from Igaku‐Shoin, Seiwa‐Shoten, and Nihon Bunka Kagakusha. None of these companies manufacture drugs or products for preoperative IMT. The Japanese Ministry of Education, Science, and Technology; the Japanese Ministry of Health, Labor and Welfare; and the Japan Foundation for Neuroscience and Mental Health have funded his research projects.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, outcome: 1.1 PPC; Atelectasis.
5
5
Forest plot of comparison: 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, outcome: 1.2 PPC; Pneumonia (Type of surgery).
6
6
Forest plot of comparison: 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, outcome: 1.3 PPC; Pneumonia (Type of intervention).
7
7
Forest plot of comparison: 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, outcome: 1.8 Duration of hospital stay.
8
8
Funnel plot of comparison: 1 Preoperative inspiratory muscle training versus usual care, non‐exercise intervention, outcome: 1.2 PPC; Pneumonia (Type of surgery).
1.1
1.1. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 1 PPC; Atelectasis.
1.2
1.2. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 2 PPC; Pneumonia (Type of surgery).
1.3
1.3. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 3 PPC; Pneumonia (Type of intervention).
1.4
1.4. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 4 PPC; mechanical ventilation > 48 hours.
1.5
1.5. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 5 All‐cause postoperative death.
1.6
1.6. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 6 Adverse events.
1.7
1.7. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 7 Maximal inspiratory muscle strength; Pi‐max (postoperative change from preoperative baseline).
1.8
1.8. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 8 Duration of hospital stay.
1.9
1.9. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 9 Total drop‐out from the study.
1.10
1.10. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 10 Sensitivity analysis; PPC; Atelectasis (Excluding studies with high risk or unclear risk of bias in allocation concealment).
1.11
1.11. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 11 Sensitivity analysis; PPC; Pneumonia (Excluding studies with high risk or unclear risk of bias in allocation concealment).
1.12
1.12. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 12 Sensitivity analysis; PPC; Atelectasis (Excluding studies with high risk or unclear risk of bias in blinding of outcome assessment).
1.13
1.13. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 13 Sensitivity analysis; PPC; Pneumonia (Excluding studies with high risk or unclear risk of bias in blinding of outcome assessment).
1.14
1.14. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 14 Sensitivity analysis; PPC; Atelectasis (worst‐case scenario analysis).
1.15
1.15. Analysis
Comparison 1 Preoperative inspiratory muscle training (IMT) versus usual care, non‐exercise intervention, Outcome 15 Sensitivity analysis; PPC; Pneumonia (worst‐case scenario analysis).
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References to ongoing studies

NCT01321983 {unpublished data only}
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NCT01828632 {unpublished data only}
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