الفهرس 
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Abstract
Upper abdominal surgery is defined as “any surgical procedure performed through an incision into the abdomen above or extending above the umbilicus”. The frequency of upper abdominal surgery for geriatric patients has been increased in recent years as aging process is accompanied with increase in the occurrence of gastrointestinal disorders that demand surgical interventions. This surgery is associated with a high risk for developing postoperative pulmonary complications for older adults; including atelectasis or pneumonia or respiratory failure. These are the leading cause of increased perioperative mortality and increased duration of hospital stay after abdominal surgery. Prevention of pulmonary complications after upper abdominal surgeries through the use of lung expansion modalities has been reported to be an effective method in reducing incidence of these complications. Of these modalities, deep breathing exercises help to inflate alveoli and reverse postoperative hypoxemia, and incentive spirometers are mechanical devices developed to encourage the patient to take long, deep, slow breaths that increase lung inflation and improve lung air-volume.
Aim of the study:
The present study aimed to determine the effect of deep breathing exercises versus the incentive spirometry on the incidence of pulmonary complications among geriatric patients undergoing upper abdominal surgeries.
Materials and Method:
A-Materials:
Design: The study followed a quasi-experimental research design.
Setting: The study was conducted at two of the surgical departments affiliated to the Alexandria Main University Hospital and specialized in upper abdominal surgeries. These are the Hepatic and Pancreatic surgical department, and the Gastrointestinal surgical department.
Subjects: The study included sixty (60) geriatric patients aged 60 years and above, undergoing upper abdominal surgery, able to communicate, have no cognitive impairment, with no cerebrovascular disease or decompensated cardiac problems or preoperative respiratory problems or postoperative peritonitis, not planned for laparoscopic surgery and accept to participate in the study. The selected subjects were randomly assigned to three groups:
- group I: included 15 geriatric patients, those received the deep breathing exercises.
- group II: included 15 geriatric patients, those used the incentive spirometry therapy.
- group III: the control group included 30 geriatric patients, who were left to the routine hospital care.
Tools of the study: Four tools were used for data collection.
Tool (1): Mini Mental State Examination (MMSE) Scale was used to assess the cognitive function of geriatric patients.
Tool (2): Socio-demographic and health profile for the geriatric patients structured interview schedule was developed by the researcher and it consists of two parts:
Part I: Socio-demographic characteristics of elders such as age, sex, marital status, educational level, job before retirement and income.
Part II: The health profile of the geriatric patients including past and present medical and surgical history, laboratory investigations within the last month, and calculation of body mass index.
Tool (3): ARISCAT risk index (2010 (was used to assess the overall risk for developing postoperative pulmonary complications for surgical geriatric patients. This index consists of seven independent risk factors to be assessed after the surgery. These risk factors include advanced age, low preoperative oxygen saturation, respiratory infection within the last month, preoperative anemia, upper abdominal incision, surgery lasting more than two hours, emergency surgery.
Tool (4): Melbourne group Scale (1999), second version, is a checklist consisting of eight criteria which are categorized as clinical and diagnostic criteria. It was used as a diagnostic tool to identify postoperative pulmonary complications (atelectasis and pneumonia) after upper abdominal surgery. Geriatric patients are identified as having postoperative pulmonary complications if they are presenting with four or more of the following eight criteria: abnormal breath sounds on auscultation which differ from preoperative assessment, purulent sputum differing from preoperative status, oxygen saturations <90% on room air, raised temperature >38C on more than one consecutive postoperative day, raised white blood cell count (>11.2 x 109/L) , chest x-ray findings of atelectasis or consolidation, physician prescription of an antibiotic for respiratory infection, and presence of infection on sputum culture.
B- Method:
- The necessary approvals were obtained from the responsible authorities.
- The Arabic version of tool I (Mini Mental State Examination (MMSE) Scale was used in this study to exclude geriatric patients with moderate or severe cognitive impairment.
- Tool II (Socio-demographic and health profile for the geriatric patients structured interview schedule) was developed by the researcher.
- Tool III (ARISCAT risk index) and tool IV (Melbourne group Scale) were translated into Arabic language by the researcher and tested for content validity and reliability.
- A pilot study was carried out on six geriatric patients to assess the clarity and applicability of the tools.
- The proposed educational program of lung expansion modalities namely deep breathing exercises and incentive spirometer for geriatric patients undergoing upper abdominal surgery was developed by the researcher and covered the following topics ;. age-related changes of the respiratory system, benefits of lung expansion modalities either deep breathing exercise or incentive spirometer use, simple instructions and illustrations for each step of the deep breathing exercise/ incentive spirometer use. This program aimed to encourage and motivate the geriatric patients to demonstrate and practice deep breathing exercise/or use incentive spirometer correctly in order to prevent the occurrence of postoperative pulmonary complications after upper abdominal surgery. The lung expansion educational program was implemented through 6 sessions, three sessions preoperatively (on 1st, 2nd, and 3rd day after hospital admission), and the other three sessions postoperatively (on 1st, 3rd, and 6th postoperative day).
- An illustrative booklet was developed by the researcher to be used in teaching the geriatric patients undergoing upper abdominal surgeries the proper technique of deep breathing exercises and incentive spirometer use.
- The researcher visited each of the study settings the next day of the scheduled outpatient clinic in order to meet the newly admitted geriatric patients and to identify those fulfilling the study criteria. Eligible geriatric patients were interviewed individually to assess their cognitive status using Mini Mental State Examination (MMSE) (tool I). Those with no cognitive impairment were included in the study and assigned either to study group (I or II) or control group (III) using consecutive sampling technique. Subjects assigned to study group I received deep breathing exercises, and subjects in study group II received incentive spirometer therapy. Whereas, subjects assigned to the control group followed the routine hospital care.
- Evaluation of the effect of the lung expansion educational program was done through assessing the respiratory status for each geriatric patient in the study and control groups after upper abdominal surgery using Melbourne group Scale (tool V) three times to identify the presence of postoperative pulmonary complications. The evaluation was on the first, the third, and sixth postoperative day.
- Data were collected from the first of January 2019 until the end of June 2019.
- Ethical considerations: an oral informed consent was obtained from each geriatric patient fulfilling the study criteria after being informed about the purpose of the study, the schedule of sessions, and that they were free to withdraw from study anytime. Privacy of the study subjects was maintained and confidentiality of the collected data was assured.
- The statistical Package for Social Science (SPSS) was utilized for data analysis and tabulation. The level of significance for this study was less than or equal to 0.05.
Results:
The main results of the study were:
- The age of the study and control subjects ranged from 60 to 75 years with a mean age of 65.773.9 and 68.574.02 for the study and control groups respectively. Females constituted 70% and 63.3% of the subjects in the study and control groups respectively, 56.7%, and 66.7% of the study and control groups respectively were married, 70% and 56.6% of the study and control groups respectively were either illiterate or just read and write. Regarding occupation before retirement, 63.3% and 60% of subjects were housewife, followed by 16.7% and 33.3% were skilled workers in the study and control groups respectively. Hypertension was prevalent in both the study and control groups (43.3%, and 40% respectively).
- As regards the preoperative respiratory status, 93.3 % of the geriatric patients in the study groups, compared to 96.7 % of those in the control group had SpO2 equal to or greater than 96%. Absence of obstructive sleep apnea was reported by 90% and 83.3% respectively of subjects in the study and control groups. Non- smokers geriatric patients were reported by 83.3% of those in the study groups, compared to 56.7% of those in the control group.
- The mean body mass index (BMI) for the study groups was 26.7861.12 kg/ m2, compared to 30.0841.99 kg/ m2 in the control group.
- The albumin level greater than 3.2 g/dl was reported by 80% and 56.7% of geriatric patients in the study and control groups respectively. As regards the hemoglobin level, 70% and 63.3% respectively in both the study and control groups had hemoglobin level greater than 10 g/dl.
- Cholecystectomy was the most common surgery performed for geriatrics in both the study and control groups (36.7 %, and 23.3% respectively), followed by gastrectomy (20% for each). Duration of surgery ranged from 2 to 3 hours was reported for both groups with the same percentage (63.3% for each).
- By applying ARISCAT scale postoperatively, 36.7% of elders in the study groups were classified as at high- risk for developing postoperative pulmonary complications, compared to 46.7% of the control group.
- No statistically significant difference was observed between practicing the deep breathing exercises or using incentive spirometer regarding the occurrence of postoperative pulmonary complications during the first six postoperative days using Melbourne scale. (P= 1.000) Only one case (6.7% ) of the geriatric patients in each of the deep breathing exercise or incentive spirometer groups showed these complications on the 6th postoperative day, compared to nearly two thirds (60% ) of elders in the control group with a statistically significant difference was found between elders in either deep breathing exercise or incentive spirometer group and their controls regarding incidence of postoperative pulmonary complications (P=0.000 for each).
- A statistically significant difference was found between either any of the study groups (deep breathing exercise/ incentive spirometer) and the control group regarding the postoperative SpO2 value and presence of adventitious breathing sound on chest auscultation on the 3rd and 6th postoperative day (P= 0.000, P=0.000 respectively). While no statically significant difference between the deep breathing and incentive spirometer group was confirmed related to these criteria (P=1.000, P=1.000 respectively).
- The duration of hospital stay for geriatric patients in the study groups ranged from 11 to 14 days with a mean of 11.890.712 days, compared to range from 11 to 42 days for the control group with a mean of 20.66.88 days. The difference is statistically significant (P= 0.0489).
- Postoperative pulmonary complications in upper abdominal surgery is significantly associated with age above 70 years (OR= 1.525, P= 0.000), male gender (OR= 2.683, P= 0.010), history of smoking (OR= 6.397, P= 0.002), Body Mass Index above 30KG/m2 (OR= 3.111, P= 0.000), partially functional dependency (OR= 3.017, P= 0.000), duration of surgery more than 3 hours (OR= 5.00, P= 0.014).
Conclusion:
It can be deduced from the study that the application of either deep breathing exercises or incentive spirometer proved to be evenly effective in reducing the incidence of postoperative pulmonary complications for geriatric patients after upper abdominal surgeries, with no significant difference between practicing deep breathing exercises and using incentive spirometer. Moreover, the occurrence of postoperative pulmonary complications for those elders performing any of the two previously prescribed modalities proved to be significantly lower than those in the control group “i.e. elders who didn’t practice any lung expansion strategy”.
The main recommendations were:
1- In-service training programs for nurses in the various upper abdominal surgery departments about the importance of applying the different lung expansion modalities particularly deep breathing exercises and incentive spirometer preoperatively or geriatric patients undergoing upper abdominal surgery in order to prevent postoperative pulmonary complications.
2- Nurses should teach the newly admitted geriatric patients to upper abdominal surgery departments about the importance and the proper technique of practicing lung expansion modalities in order to reduce the incidence of postoperative pulmonary complications. As well as, nurse should motivate and encourage geriatric patients to practice any of these modalities regularly during the preoperative and postoperative period in order to gain its effectiveness.
Assessment of respiratory status for every geriatric patient undergoing upper abdominal surgery should be an integral part of the comprehensive assessment for these patients in order to identify early those at risk to develop postoperative pulmonary complications.