Applying Cardiac Rehabilitation Exercise Protocol to Reduce Post-operative Cardio-Pulmonary Complications among Open Heart Surgery Patient's

Introduction

Cardiac surgery is a well-established procedure worldwide with excellent results for efficacy and safety in treating heart patients. Cardiac surgery, including coronary artery bypass, valve surgery, and congenital defect repair, is among the most common classes of surgical procedures performed worldwide. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. (Stephens & Whitman, 2015) & (da Costa Torres, 2016)

The incidence of postoperative complications after cardiac surgery is reported according to the specific complication, presence of comorbidities, and patient related factors (e.g., age). Factors such as age, duration of extracorporeal circulation (ECC), and respiratory complications (including atelectasis, pleural effusion, and respiratory failure) may increase the length of hospital stay. (Ettema, et al., 2014 & Cordeiro, et al., 2017)

Major complications include cardiac, respiratory, and renal dysfunction, as well as gastrointestinal and neurological complications. The pathogenesis behind postoperative complications involves hemodynamic and inflammatory signaling pathways, which activated in response to cardiac arrest, artificial and non-pulsatile circulation, hypothermia, blood contact with the artificial surface of cardiopulmonary bypass (CPB) and the surgical insult with skin incision and sternotomy. (Enger, 2017)

In surgery, it is important for patients to go into the theatre fully prepared physically and emotionally regarding the procedures they are about to go through. Surgical patients go through either planned (elective) or emergency surgery. In planned surgeries, patients go through a multidisciplinary team of experts’ examination depending on the patient’s condition. Some of these experts include the nurse, the anesthetist, the surgeon, the clinical psychologist, laboratory technician and others. (Adugbire, et al., F. 2017)

Patients recovering from cardiac surgery may be referred to a cardiac rehabilitation (CR) program. The aim of CR is to increase survival, reduce cardiovascular disease (CVD)-related morbidity and hospital admissions, improve functional capacity, quality of life and facilitate early return to work.Structured exercise training is one of the essential components of cardiac rehabilitation and may make the largest contribution to increasing patient survival. (Nichols, et al., 2018)

After cardiac surgery, inpatient cardiac rehabilitation (ICR) contributes significantly to the pre­vention of lung complication and decondition caused by pro­longed bed rest, thus to early recovery. Exercise therapy is the essential component of ICR which composed of breathing exercises, early mobilization, and strength exercises therapy. (Seo, et al., 2017)

The cardiac rehabilitation exercise program during hospitalization consists of respiratory physiotherapy, neck and shoulder exercises, walking and cycling. The purpose is to prevent respiratory complications such as atelectasis and pneumonia, neck and shoulder pain and increasing the physical functional level. (Højskov, et al., 2017)

It is important that nurses educate surgical patients on the importance of deep breathing and coughing, regular gentle leg exercise and early mobilization to reduce the risk of postoperative complications (Snowdon, et al., 2014).

Significance of the Study:                                                                                        

The documented incidence of post-operative complications ranges from 3% to 16% after Coronary Artery Bypass Graft and 5%-7% after valvular heart surgery. (Naveed, et al., 2017) The cumulative incidence of pulmonary complications was 15.08% with a mortality rate of 18.5% from patients who developed complications and overall mortality among all patients was 2.79%. Pulmonary complications occurred in 7.82% of patients with coronary artery revascularization, 2.23% in patients with valvular replacement and 5.05% in patients with congenital heart disease. (Al-Qubati, Damag & Noman, 2013)

Aim of the Study

The aim of the present study was to evaluate the effect of applying cardiac rehabilitation exercise protocol for open heart surgery patient's to reduce post-operative cardio-pulmonary complications

Research Hypothesis

To fulfill the aim of the study, It is hypothesized that the patients undergoing open heart surgery who will be exposed to cardiac rehabilitation exercises (study group) will have a lower incidence of cardio-pulmonary complications compared to the (control group). 

Subjects and Methods

Research Design

Quasi-experimental research design was utilized in the current study.

Setting:-

This study carried out in the inpatient cardiac surgery department of Cardio-thoracic Surgery Hospital at New Minia City. 

Subjects:

A purposive sample of 60 patients was collected through fourteen (14) month and they were classified equally into two groups; (n =30) for control group and (n =30) for study group who were willing to participate in the current study. Both groups in the current study were selected according to the following inclusion and exclusion criteria:   

Inclusion Criteria:- 

• All adult (18-60 years) patients admitted in cardiac surgery department two days before open heart surgery
• Hemodynamically stable
• Conscious

Exclusion Criteria:-

• Patients undergoing invasive or noninvasive mechanical ventilation for a period exceeding 24 hours after admission to the Intensive Care unit (ICU).
• Patients contraindicated to perform the exercise
• Any complications other than cardiopulmonary complications

Tools of Data Collection:-

• The current study data was collected by using three tools that were developed by the investigator after revising extensive relevant literature review and reviewed by a panel of nine experts, fourth in the field of Medical Surgical Nursing Faculty of Nursing Ain- Shams University and three in the field of Medical Surgical Nursing Faculty of Nursing Minia University and two in the field of cardiac surgery Faculty of Medicine at Minia University for validity testing. These tools are as following:-

First Tool:  Health Assessment Sheet: It includes two Parts:

• 1^st Part: Socio- demographic data as name, age, gender, level of education and marital status, occupation, income and phone number.
• 2^nd Part: Medical data, based on (Lewis, et al., 2014) as: medical diagnosis, type of surgery, presence of chronic diseases, smoking and body mass index (BMI), hemodynamic variables (Temperature, Heart Rate, Blood pressure, Respiration, and Oxygen Saturation)

Second Tool: Cardiac Rehabilitation Exercise Checklist which includes two Parts: adopted from (García, et al, 2014)

• 1^st Part:  Respiratory Physiotherapy consisted of 11 step (Incentive Spirometer include 3 steps, Deep Breathing include 4 steps and Breath and Cough include 4 steps)
• 2^nd Part: Upper and Lower LimbExercisesconsisted of 58 step (upper and lower limb ROM include 48 step, walking include 3 steps and sternal precautions include 7 steps)
• They were applied to reduce the postoperative cardio pulmonary complications among open heart surgery patients.
• Scoring system: The maximum score value was 69 (respiratory physiotherapy 11 point and upper & lower limb exercises 58 point), each item was observed, categorized, and scored into either done =1 or not done= 0 on all items of the checklist. These scores are further classified as unsatisfactory level (less than 60%), and satisfactory level more than 60%).

Third Tool: Cardiopulmonary Complications Assessment Sheet based on (Kashmiri, et al., 2012):

• This tool used to evaluate the effect of the applied cardiac rehabilitation exercise protocol on the occurrence of postoperative cardiac and pulmonary complications among open heart surgery patients.
• The investigator assessed the patient for presence of cardiac complications as (Impaired Cardiac output syndrome, Cardiac Arrhythmias) or pulmonary complications (Respiratory tract infection, Pneumothorax, Hemothorax or ARDS) before discharge (after applying the cardiac rehabilitation exercise protocol).

Tools Validity:-

Content validity was done to identify the degree to which the used tools measure what was supposed to be measured. The developed tools were examined by a panel of nine expert's opinion in the field of the study, one assistant professor and two lecturers of Medical Surgical Nursing at Minia University - Faculty of Nursing and two assistance professors of cardiac surgery Department Faculty of Medicine at Minia University and three professors and one assistant professor of Medical Surgical Nursing at Ain- Shams University and according to their opinion some modifications were applied.

Tools Reliability:-

Reliability was ascertained statistically by using Alpha Cronbach test to ensure that the study tools are reliable. Reliability of Health Assessment sheet, Cardiac Rehabilitation Exercise Checklist and Cardiopulmonary Complications Assessment Sheet were (0.96, 0.71 and 0.86) respectively.

Pilot Study:-

A pilot study was carried out on 10% (n = 6) of the total sample to test the clarity of tools and estimate the time required for fulfilling it. Based on results of the pilot study some modifications were done and the subjects were not included to the actual sample.

Ethical Considerations:-

An official permission to conduct the study was obtained from the Ethical committee in the Faculty of Nursing, Dean of Faculty of Nursing, and Manager of Cardiothoracic Minia University Hospital, and agreement from Egypt Academic for Research Center and Technology to carry out this study. Subject's participant  in this study were voluntary and each involved subject were informed about the purpose, procedure, benefits, and nature of the study, and that he/she had the right to withdraw from the study at any time without any rationale, then written consents were obtained. Confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data.

Educational Training Practices about the Cardiac Rehabilitation Exercise Protocol formulated by the investigator after revising extensive relevant literature review such as (García, et al., 2014) &  (Højskov, et al., 2017).They were applied to reduce the postoperative cardiopulmonary complications among open heart surgery patients. Arabic booklet was included which covered; Introduction of the Cardiac Surgery, Importance of Exercises, and Complete Description of Each Exercise (deep breathing exercise include 4 steps, deep breath and cough include 4 steps and Incentive spirometer include 3 steps, upper and lower limb range of motion include 48 step, walking include 3 steps and sternal precautions 7 steps)

The investigator had trained the study subjects about the educational cardiac rehabilitation exercise booklet in the preoperative phase to ensure the subjects ability to perform these exercises postoperatively.

The investigator asked the participants to perform breathing exercises (7–10 breaths and incentive spirometer 3–5 min) 4 times a day. Physical exercises include shoulder and head exercises, resistance training, leg endurance and walking (10 sessions of each exercise two times per day from postoperative day 1 until hospital discharge.

Procedure:-

Preparatory Phase:

(Assessment and planning phase) It included reviewing of the current and relevant related literature and theoretical knowledge of the various related aspects using books, articles, internet, and periodical magazines in order to develop the data collection tools. Exploring prevalence of patient at cardiac surgical ward and incidence of cardiopulmonary complications among those patient's

Implementation Phase:

This phase includes the preoperative and postoperative period and during this phase the cardiac rehabilitation exercise training protocol was implemented.

Pre-operatively:

Selected subjects (according to inclusion and exclusion criteria) were admitted to inpatient cardiac surgery department, Patients were equally enrolled in this study as control and study groups. The investigator obtained written consent from those (study and control group) who accepted to participate in this study. For the study group, patients who were scheduled for the cardiac rehabilitation exercise protocol were informed by the investigator individually about purpose and nature of the study

The investigator has started data collection from control group firstly by using the first and second tools (Health assessment sheet and the cardiac rehabilitation exercise checklist to assess the patients baseline data about the cardiac rehabilitation exercises) these data was collected by the investigator preoperatively for only one time.

Preoperative training about the educational cardiac rehabilitation exercise booklet over a period of one or two days was done by the investigator to each participant for the study group through face to face interview to follow the prescribed instructions. The total number of sessions for data collection & training of the study group patient was 2 - 3 sessions preoperatively varied according to each participant understanding. Duration for each session was ranged from 30 to 45 minutes.

The first session (overview about cardiac surgery); at the beginning of this session, the investigator introduce herself and explained the objective of the research; each study group patients was given an educational cardiac rehabilitation exercise booklet, the investigator illustrated the content of the booklet, give the patients simple information about anatomy of the heart, physiology of the heart, cardiac surgery, and preoperative routine events.

The second session (Pre and postoperative exercises); the investigator gave the patients a detailed explanation about each exercise and help the patients develop skills related to respiratory physiotherapy (deep breathing, coughing exercise and incentive spirometer), change positioning, ambulation and extremities exercises and also instructions regarding duration and frequency of each previous skill. 

Demonstration and re-demonstration was done to ensure that each patient perform these exercises accurately. On the other hand; the investigator trained the nursing staff in the cardiac surgery department as co- investigator who had shift in the same study setting to follow up the study group who was applied the cardiac rehabilitation exercise protocol in accurate time during their specific work shift.

Postoperatively:

The investigator assessed adult patients undergoing open heart surgery through daily basis from surgery day until discharge during morning and evening shift at inpatient cardiac surgery department. The assessment tools were collected from control group firstly then started the collection for other study group.

Evaluation Phase:

The last phase of proposed teaching program is the evaluation phase. The investigator assessed both study and control group by using the second tool to evaluate the patient's performance of cardiac exercises after applying the cardiac rehabilitation exercise protocol (before discharge).

The investigator assessed patients for the presence of any cardiac or pulmonary complications using the third tool. (Cardiopulmonary Complications Assessment Sheet) The investigator assessed the presence of complications before the patient discharge from hospital signs and symptoms of complications was reported by the investigator after being observed by two physicians to confirm the absence of inter-observer variability. 

Statistical Analysis of Data:

Data were summarized, tabulated, and presented using descriptive statistics in the form of frequency distribution, percentages, means and the standard deviations as a measure of dispersion. A statistical package for the social science (SPSS), version (20) was used for statistical analysis of the data, as it contains the test of significance given in standard statistical books. Numerical data were expressed as mean & SD. Qualitative data were expressed as frequency and percentage. Probability (P-value) is the degree of significance, less than 0.05 was considered significant. The smaller the P-value obtained, the more significant is the result (*), less than 0.001 was considered highly significant (**) and correlation coefficient was done by using Pearson correlation test.

Results

Table (1): Distribution of Both Study and Control Groups Regarding to Their Socio-demographic Data (n=60)

NS= Not Significant

Table (1): Reveals distribution of the studied subjects according to the Socio-demographic data. In relation to age, the mean age among study and control groups was nearly similar (40.7 ± 12.3 and 44.9 ±11.5) respectively. Regarding to gender it was found that the highest percentages among study and control group were female (63.3%, and 56.7%) respectively. Regarding occupation; it was seen that the highest percentages among study and control group were employer (50% and 46.7%) respectively.

In relation to education levels it was found that the largest percent, (33.3%, 30 %) of study and control groups respectively were illiterate. Concerning marital status, the finding represented that the highest percentage among study and control group were married (83.3%, 73.3%) respectively. There was no statistical significance difference between the two groups regarding to socio-demographic data at (P ≤ 0.05)

Figure (1): Distribution of both Study and Control Group Regarding to Medical Data

Figure (1) Shows that the highest percentages of both groups (study and control) were having rheumatic heart disease (56.7% & 63.3%) respectively. As regarding type of surgery; it was found that the highest percentage of both groups (study and control) had valve surgery (83.3% & 76.7%) respectively. Regarding presence of chronic illness; it was observed that the highest percentage of both groups (study and control) had hypertension(30% and 23.3%) respectively, while (16.7 % and 20%) had diabetes mellitus respectively.

Figure (2): Distribution of both Study and Control Group Regarding to Smoking and BMI

Figure (2) Shows that the highest percentage of both groups (study and control) were none smoker (66.7% and 73.3%) respectively, while (23.3% and 20 %) of them respectively were smoke 10-20 cigarettes/day. Regarding to BMI it was found that the highest percentage of both groups (study and control) were in the normal BMI score (56.7) for each group.

Table (2): Distribution of Study and Control Group Regarding Level of Performance Pre and Post Implementing Cardiac Rehabilitation Exercise Protocol (n=60)

   ** Highly Statistical Significant Difference (P ≤ 0.01)

Table (2) Reflected that there were no statistical significant differences between study and control group regarding performance of the cardiac rehabilitation exercise protocol pre intervention.While the findings showed a highly significant improvement between the study and control group post intervention (after implementing the cardiac rehabilitation exercise protocol) as documented by p value (0.000)

Figure (3): Mean Score of Study and Control Group Regarding Level of Performance Post Implementing Cardiac Rehabilitation Exercise Protocol (n=60)

Figure (3) Reflected that the mean score of all items regarding each exercise level of performance was increased in study group compared to control group post implementing cardiac rehabilitation exercise protocol. Moreover a highly statistical significant difference was found as documented by p values (0.000) for all items sores.

Table (3): Mean Score of Study and Control Groups Regarding to Their hemodynamic variables Pre and Post Implementing the Cardiac Rehabilitation Exercise Protocol (n=60)

P-value1: t test         P-value2: Anova          (1^st day: Pre intervention)        (2^nd to 5^th day: Post intervention)   

* Statistical significant (P ≤ 0.05)   ** highly Statistical significant (P ≤ 0.01)

Table (3): Displayed that, there were highly statistical significant differences between both groups regarding to temperature during 4^th and 5^th day post intervention documented by p value (0.004 and 0.006) respectively. The table reflected that, there were high statistical significant differences among both groups regarding to the respiration during 2^nd day post intervention documented by p value (0.001). Also there were statistical significant differences among both groups regarding the respiration during 3^rd, 4^th and 5^th day post intervention documented by p value (0.049, 0.05 and 0.029) respectively. 

As regard to pulse there were statistical significant differences among both groups during 2^nd, 3^rd, 4^th, and 5^th day post intervention documented by p value (0.013, 0.029, 0.021 and 0.024) respectively. As regard to the systolic and diastolic blood pressure there were no statistical significant differences among both groups along the 1^st five days post intervention.

From the same table it was noticed that there were statistical significant differences among both groups regarding oxygen saturation during 3^rd day post intervention documented by p value (0.04), moreover, there were high statistical significant differences among both groups during  4^th and 5^th  day post intervention documented by p value (0.001 and 0.000) respectively.         

Table (4): Comparison between the Study and Control Groups Regarding Effect of Cardiac Rehabilitation Exercise Protocol on Reducing Postoperative Cardiopulmonary Complications  

* Statistical Significant Difference (P ≤ 0.05)  

Table (4): Showed that, (20%) of study group have ICO syndrome as a cardiac complication early before discharge, compared to (30%) of control group before discharge, There were statistical significant differences among both groups regarding cardiac complication during early post-operative reflected by P-value = 0.027

Moreover; it was found that, (3.3%) of study group had RTI as a respiratory complication compared to (20%) of control group. There were statistical significant differences among both groups regarding respiratory complication during early post discharge reflected by P-value = 0.038    

Table (5): Correlation between Age, BMI, Chronic Illness, & Smoking and Occurrence of Cardiopulmonary Complications:

* Statistical Significant Difference (P ≤ 0.05)   

Table (5) showed that, there were no statistical significant correlation between occurrence of cardiac complications and age, BMI, chronic illness and smoking among study and control group as documented by r value (0.067& 0.30), (0.25& 0.075), (0.030& 0.076) and (-0.021& -0.025) respectively.. As well as there were no statistical significant correlation between occurrence of respiratory complications and age, BMI, chronic illness and smoking among study and control group as documented by r value (0.370 & 0.247), (0.22 & 0.20), (0.125 & 0.313) and (0.125 & 0.25) respectively.

Table (6): Multiple Linear Regression Model Evaluating the Relationship between Cardiac Rehabilitation Exercise Protocol and Early Postoperative Complications:

* Statistical Significant Difference (P ≤ 0.05)

Table (6) Predicted that, the cardiac rehabilitation exercise protocol will decrease the occurrence of respiratory and cardiac complications, the regression model, shows the negative relation between cardiac rehabilitation exercise protocol and occurrence of respiratory and cardiac complications with significance to respiratory complications only as documented by p value (0.042).