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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the article by Rodrigues et al&#46; entitled &#8220;Effectiveness of preoperative breathing exercise intervention in patients undergoing cardiac surgery&#58; a systematic review&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> In their paper&#44; the authors performed a systematic review of the literature to assess the impact of breathing exercise training on postoperative pulmonary complications &#40;PPC&#41; and length of hospital stay&#46; Given the importance of respiratory therapy in cardiac patients&#44; we hoped to find a more accurate description of the interventions and outcomes mentioned&#46; Also&#44; considering some of the terms used for the literature research &#8211; which are vague and refer to non-comparable interventions &#8211; as well as of some used in the text&#44; we are concerned about the authors&#8217; familiarity with the concepts they are discussing and with the potentially incorrect interpretation and selection of the studies included&#46; As an example&#44; &#8216;breathing exercise therapy&#8217; is a vague and imprecise term&#44; as are &#8216;mobilization scheme&#8217;&#44; &#8216;respiratory parameters&#8217; and &#8216;respiratory performance&#8217;&#44; which were not precisely described&#46; The interventions of the included randomized clinical trials &#40;RCTs&#41; were not limited to diaphragmatic breathing&#44; inspiratory muscle training &#40;IMT&#41; or incentive spirometer&#44; as indicated by the authors in Table 2&#59; therefore&#44; their conclusions concerning the techniques targeted by the review may be biased&#46; Thus&#44; stating that a &#8220;breathing therapy program&#8221; could only include IMT&#44; breathing exercises or both is reductive and incorrect&#46; We would like to clarify that respiratory physiotherapy includes a wide range of interventions &#40;succinctly&#58; breathing strategies and techniques for lung expansion&#44; bronchial hygiene techniques&#44; respiratory muscle assessment and training&#44; and exercise&#41; aimed at specific respiratory disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> More specifically&#44; breathing techniques can be used for different purposes<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#8211;4</span></a> and may include diaphragmatic breathing &#40;which reduces respiratory rate and dyspnea&#44; and improves ventilation&#41;&#44; deep breathing exercises &#40;which improve lung expansion and ventilation&#44; noting&#44; however&#44; that volume recruitment should be done using an Ambu bag&#44; cough assist device or ventilator&#41;&#44; and pursed lip breathing &#40;which reduces lung hyperinflation&#44; respiratory rate and dyspnea&#44; resulting in more efficient ventilation&#41;&#46; For surgical patients&#44; breathing control and ventilation&#47;perfusion ratio optimization techniques &#40;considering the increased risk of lung atelectasis due to restrictive and shallow breathing patterns secondary to sternal pain&#41;&#44; bronchial hygiene techniques &#40;especially among mechanically ventilated patients in view of the increased respiratory infection risk and the presence of non-ventilated lung areas&#41;&#44; IMT &#40;since pain and sternotomy may result in temporary decreased respiratory muscle strength&#41;&#44; and aerobic exercise and resistance training &#40;as recommended for all hospitalized patients&#41; are indicated&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Finally&#44; we strongly disagree with the authors when they question the need to use threshold IMT&#44; since they are comparing interventions with different purposes and indications&#46; Besides&#44; this was not analyzed or discussed in any of the RCTs included&#46; Only two studies did not include respiratory muscle training with threshold loading techniques&#46; Moreover&#44; in one of these no statistically significant difference in PPC was found between control and intervention groups&#46; The final naive and erroneous assumption that any kind of breathing therapy is equally effective is a hasty conclusion&#44; since it was not within the scope of the review and no comparative analysis was conducted&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The subject is pertinent&#46; Despite the limitations pointed out above&#44; we wish to highlight the importance of respiratory therapy in cardiac patients before and after surgical intervention&#44; since it prevents PPC&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;4</span></a> Further studies are needed in order to determine the beneficial effect of specific preoperative respiratory interventions on post-surgical complications&#46; These interventions may be directed to specific goals and to the observed alterations&#44; and should be individualized and judiciously performed by trained professionals&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Letter to the Editor
Letter to the Editor regarding “Effectiveness of preoperative breathing exercise interventions in patients undergoing cardiac surgery: a systematic review”
Carta ao editor relativa ao artigo «Eficácia de uma intervenção baseada em exercícios respiratórios em pessoas a aguardar cirurgia cardíaca: uma revisão sistemática da literatura»
Margarida Rodriguesa,
Corresponding author
90.rodriguesmargarida@gmail.com

Corresponding author.
, Inês Machado Vazb
a Centro Hospitalar Vila Nova de Gaia/Espinho – Centro de Reabilitação do Norte, Vila Nova de Gaia, Portugal
b Centro Hospitalar de Trás-os-Montes e Alto Douro – Serviço de Medicina Física e de Reabilitação, Vila Real, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the article by Rodrigues et al&#46; entitled &#8220;Effectiveness of preoperative breathing exercise intervention in patients undergoing cardiac surgery&#58; a systematic review&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> In their paper&#44; the authors performed a systematic review of the literature to assess the impact of breathing exercise training on postoperative pulmonary complications &#40;PPC&#41; and length of hospital stay&#46; Given the importance of respiratory therapy in cardiac patients&#44; we hoped to find a more accurate description of the interventions and outcomes mentioned&#46; Also&#44; considering some of the terms used for the literature research &#8211; which are vague and refer to non-comparable interventions &#8211; as well as of some used in the text&#44; we are concerned about the authors&#8217; familiarity with the concepts they are discussing and with the potentially incorrect interpretation and selection of the studies included&#46; As an example&#44; &#8216;breathing exercise therapy&#8217; is a vague and imprecise term&#44; as are &#8216;mobilization scheme&#8217;&#44; &#8216;respiratory parameters&#8217; and &#8216;respiratory performance&#8217;&#44; which were not precisely described&#46; The interventions of the included randomized clinical trials &#40;RCTs&#41; were not limited to diaphragmatic breathing&#44; inspiratory muscle training &#40;IMT&#41; or incentive spirometer&#44; as indicated by the authors in Table 2&#59; therefore&#44; their conclusions concerning the techniques targeted by the review may be biased&#46; Thus&#44; stating that a &#8220;breathing therapy program&#8221; could only include IMT&#44; breathing exercises or both is reductive and incorrect&#46; We would like to clarify that respiratory physiotherapy includes a wide range of interventions &#40;succinctly&#58; breathing strategies and techniques for lung expansion&#44; bronchial hygiene techniques&#44; respiratory muscle assessment and training&#44; and exercise&#41; aimed at specific respiratory disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> More specifically&#44; breathing techniques can be used for different purposes<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#8211;4</span></a> and may include diaphragmatic breathing &#40;which reduces respiratory rate and dyspnea&#44; and improves ventilation&#41;&#44; deep breathing exercises &#40;which improve lung expansion and ventilation&#44; noting&#44; however&#44; that volume recruitment should be done using an Ambu bag&#44; cough assist device or ventilator&#41;&#44; and pursed lip breathing &#40;which reduces lung hyperinflation&#44; respiratory rate and dyspnea&#44; resulting in more efficient ventilation&#41;&#46; For surgical patients&#44; breathing control and ventilation&#47;perfusion ratio optimization techniques &#40;considering the increased risk of lung atelectasis due to restrictive and shallow breathing patterns secondary to sternal pain&#41;&#44; bronchial hygiene techniques &#40;especially among mechanically ventilated patients in view of the increased respiratory infection risk and the presence of non-ventilated lung areas&#41;&#44; IMT &#40;since pain and sternotomy may result in temporary decreased respiratory muscle strength&#41;&#44; and aerobic exercise and resistance training &#40;as recommended for all hospitalized patients&#41; are indicated&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Finally&#44; we strongly disagree with the authors when they question the need to use threshold IMT&#44; since they are comparing interventions with different purposes and indications&#46; Besides&#44; this was not analyzed or discussed in any of the RCTs included&#46; Only two studies did not include respiratory muscle training with threshold loading techniques&#46; Moreover&#44; in one of these no statistically significant difference in PPC was found between control and intervention groups&#46; The final naive and erroneous assumption that any kind of breathing therapy is equally effective is a hasty conclusion&#44; since it was not within the scope of the review and no comparative analysis was conducted&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The subject is pertinent&#46; Despite the limitations pointed out above&#44; we wish to highlight the importance of respiratory therapy in cardiac patients before and after surgical intervention&#44; since it prevents PPC&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;4</span></a> Further studies are needed in order to determine the beneficial effect of specific preoperative respiratory interventions on post-surgical complications&#46; These interventions may be directed to specific goals and to the observed alterations&#44; and should be individualized and judiciously performed by trained professionals&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Article information
ISSN: 21742049
Original language: English
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Revista Portuguesa de Cardiologia (English edition)
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