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Does Aggressive Respiratory Rehabilitation from Early Post-Operative Period after Primary Nuss Procedure Improve Pulmonary Function for the PEX Patients?

Masahiko Noguchi, Kenya Fujita, Yuko Ichinose

Department of Plastic & Reconstructive Surgery, Nagano Children's Hospital, Azumino City, Japan


Introduction: Although the main objective for treating pectus excavatum is to cosmetically improve the appearance of chest wall, it is hoped that morphological improvement leads also to functional improvement. Nuss reported that over 95% of patients treated with Nuss procedure were satisfied with cosmetic results. However, outcomes of pulmonary function after surgery varied from no change to improvement. Johnson et al., in 2008, performed a meta-analysis concerning the effect of Nuss procedure on cardiorespiratory function. The analysis revealed FEV1 significantly increased after the bar removal while pulmonary function remained lower than before surgery.

Here, we present the efficacy of an aggressive respiratory rehabilitation program that was started from early postoperative period to improve pulmonary function after Nuss procedure.

Materials and methods: We evaluated twenty patients undergoing primary Nuss procedure at our institute. The age of the patients ranged from 4 to 15 (mean: 9.45). At the time of admission, a physiatrician provided each patient with a training instruction. For the first 4 days, patients were trained with mechanical in-exsufflation (coughAssist®PHILIPS), and then were shifted to incentive spirometer (Coach 2®PORTEX) four times a day. Pre- and post-operative at discharge, one month- and two month -inspired volumes were measured with incentive spirometer (Coach 2®PORTEX). A paired t-test was used for statistical analysis.

Results: The average pre-operative inspired volume was 1157±549ml and that at discharge was 668±361ml and the difference is statistically significant.  However, the volume increased after one month postoperatively (1215±530l), and it significantly increased after3 months post-operatively(1417±543ml).

Conclusion: The devices that we introduced have been used for pulmonary rehabilitation after surgery of the upper abdomen or thoracotomy.   Coach2 is used for incentive spirometry to increase the inspiratory volume. CoughAssist is an airway clearance device which can also set inspiratory volume, inspiratory time and pause time mechanically. Therefore, it also leads to increase the lung capacity. In addition, it is suitable at the early postoperative stage to gain inspiratory volume. These improve reduced vital capacity or restricted deep breathing due to postoperative pain. CoughAssist, particularly, is suitable at an early postoperative phase to set definite deep breathing.

We concluded that the aggressive respiratory rehabilitation after primary Nuss procedure may contributed to increasing the pulmonary function.

Keywords: precuts excavatum, pulmonary function, respiratory rehabilitation