If major surgery awaits you, consider yourself a candidate for a respiratory infection or breathing problem in the days that follow–especially, according to the American College of Physicians, if you are 60 or older, if the surgery involves general anesthesia or takes more than three hours, or if you have congestive heart failure. The risk of a postop respiratory problem has been reported to reach 88 percent. That's a number that will make you catch your breath.
The problem is that after surgery, when you're in pain or doped up and lying on your back, even breathing becomes an effort, so you tend to take regular, shallow breaths–no sighs or deep yawns to stretch and expand the lungs fully. Your diaphragm may not feel like cooperating, either. Mucus, which can harbor infectious bugs, isn't cleared out effectively.
But there's a way to fix this. Last fall a group of Dutch researchers reported in the Journal of the American Medical Association that two weeks of breathing exercises before heart bypass surgery halved the rate of postop respiratory complications in a group of high-risk patients relative to a similar second group that didn't get the training. Their incidence of pneumonia was slashed by 60 percent, and they spent an average of a day less in the hospital. The patients practiced inhaling, learning in 20-minute sessions to inhale steadily and deeply with the help of an incentive spirometer that showed how well they were doing by how high they could make a ball or cylinder rise inside a chamber. They were also tutored in coughing and deep breathing. To the amazement of JAMA readers who wrote in with questions, not a single patient dropped out.
The study was small, with a total of 279 patients. But the results were so promising that early next month, at the annual meeting in Vancouver of the World Confederation of Physical Therapy, a researcher at the University of Western Ontario will call for such training to become standard practice for all patients, high risk or otherwise, who face heart bypass surgery. "The evidence seems to say it works," says Tom Overend, an associate professor in the school of physical therapy who has conducted his own studies of such techniques. "It's called prehabilitation."
The hitch, Overend explains, is not clinical; it is time and resources. "It's difficult sometimes to see these people before surgery," he says. "Sometimes the first time is the day before." And there's the money question. In the JAMA study, the cost of the training came to 300 euros per patient, or about $400. In a rational health system, that expense would be set alongside the substantial savings from one less day of care and the many fewer cases of costly complications. Under the current system, though, who would pay for the training is one more argument to be put to administrators of Medicare and to private insurers. And hospitals profit from patients who develop complications.
You know, $400 sounds like a bargain to me. So much of one, in fact, that if I were going under the knife for major surgery and fell into any of the obvious risk categories, I'd consider paying for the training myself. If you're inclined that way, your primary-care doctor may be able to recommend a respiratory therapist. If not, the pulmonary department at a nearby hospital should have suggestions.
U.S. News's Avery Comarow has been editor of the America's Best Hospitals annual rankings since they first appeared in 1990. His reporting on clinical medicine, from the latest cholesterol guidelines to robotic surgery, has been driven by the question: What does this mean to patients? And that is the perspective he brings to his observations and commentaries on the increasing number of programs by hospitals and other healthcare providers to improve care and patient safety.
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