Acta Anaesthesiol Scand 2010; 54: 261267 Printed in Singapore.

All rights reserved

r 2009 The Authors Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2009.02143.x

Review Article

Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review
Department of Intensive Care, Linkoping University Hospital, Linkoping, Sweden, 2Department of Medical Sciences, Clinical Physiology, Uppsala University Hospital, Uppsala, Sweden and 3Department of Physiotherapy and Centre for Health Care Sciences, Orebro University Hospital, Orebro, Sweden

J. ORMAN1 and E. WESTERDAHL2,3

1

A variety of chest physiotherapy techniques are used following abdominal and thoracic surgery to prevent or reduce post-operative complications. Breathing techniques with a positive expiratory pressure (PEP) are used to increase airway pressure and improve pulmonary function. No systematic review of the effects of PEP in surgery patients has been performed previously. The purpose of this systematic review was to determine the effect of PEP breathing after an open upper abdominal or thoracic surgery. A literature search of randomised-controlled trials (RCT) was performed in ve databases. The trials included were systematically reviewed by two independent observers and critically assessed for methodological quality. We selected six RCT evaluating the PEP technique performed with a mechanical device in spontaneously breathing adult patients after abdominal or thoracic sur-

gery via thoracotomy. The methodological quality score varied between 4 and 6 on the Physiotherapy Evidence Database score. The studies were published between 1979 and 1993. Only one of the included trials showed any positive effects of PEP compared to other breathing techniques. Today, there is scarce scientic evidence that PEP treatment is better than other physiotherapy breathing techniques in patients undergoing abdominal or thoracic surgery. There is a lack of studies investigating the effect of PEP over placebo or no physiotherapy treatment.
Accepted for publication 16 September 2009 r 2009 The Authors Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation

BDOMINAL and thoracic surgery is associated with a high incidence of post-operative pulmonary complications leading to longer hospital stays and increased mortality.1 Several interventions and strategies are used to diminish these problems.2,3 Chest physiotherapy has long been a standard component of post-operative care, with the aim of preventing or reducing complications such as impaired pulmonary function, atelectasis, pneumonia, and sputum retention.4,5 In a recent systematic review, it has been concluded that continuous positive airway pressure (CPAP) decreases the risk of pulmonary complications, atelectasis, and pneumonia after abdominal surgery.6 Simple systems for positive expiratory pressure (PEP) breathing have been developed, for example, systems where a mask or a mouthpiece is connected to a resistance nipple to provide positive pressure during expiration and the blow-

bottle device in which the resistance consists of a water seal. In clinical practice, the resistance is often regulated to achieve 520 cmH2O during slightly active expiration. The pressure achieved is dependent on the performance of the manoeuvre, the adjustable expiratory resistance, and the patients active expiratory ow. The rationale for the PEP technique post-operatively is to increase pulmonary volumes, decrease atelectasis, and promote secretion removal.7,8 The physiological effects of PEP in spontaneously breathing post-operative patients are unknown, but an increased functional residual capacity (FRC) is considered essential. PEP treatment has been systematically reviewed in patients with cystic brosis9 and chronic obstructive pulmonary disease.10 No clear evidence was found that breathing exercises performed with PEP were more effective than other forms of

261

 J. Orman and E. Westerdahl

treatment.9,10 No systematic review of the effects of PEP in surgery patients has been found. Breathing exercises with PEP are often provided routinely in Scandinavia for patients undergoing surgery. The effect of PEP in post-operative care has not yet been summarised. We therefore undertook a systematic review to assess the effectiveness of breathing exercises performed with PEP in patients after open abdominal or thoracic surgery.

Methodological quality assessment

The eligible trials were systematically analysed with an instrument for methodological quality assessment. The quality criteria list used in this study was the PEDro scale,* based on the Delphi list developed by Verhagen et al.11 The methodological quality scale consists of 10 criteria for internal validity (criteria 29) and statistical information (criteria 1011), and the study achieves one score for each fullled criteria. The additional criterion 1 that relates to the external validity was not used to calculate the PEDro score in the present review, in accordance with the suggestions at the PEDro website.* The individual criteria were marked as Yes (positive) or No (negative). Data were considered missing if they were not mentioned explicitly in the text. Two reviewers assessed the methodological quality of the studies independently, and the result was then compared and discussed until agreement was achieved. Studies with a score of 5 or more on the PEDro scale were considered to be of moderate or high quality.12

Methods
Search strategy and study selection
A literature search was initially performed in October 2007 and updated in November 2008. The search was performed in the following databases: MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), The Physiotherapy Evidence Database (PEDro), and The Cochrane Central Register of Controlled Trials on the Cochrane Library. Reference lists of the retrieved articles were searched to identify any additional studies. Based on the titles and abstracts, we selected all randomised-controlled trials (RCT) evaluating the PEP technique performed with a mechanical device in spontaneously breathing adult patients after an open upper abdominal or thoracic surgery via thoracotomy. The studies had to include at least one treatment group in which the PEP technique was compared with other chest physiotherapy techniques or with no intervention. The following search words were used individually or in combinations: abdominal surgery, atelectasis, blow bottle, breathing exercises, physical therapy, physiotherapy, positive expiratory pressure (PEP), post-operative pulmonary complications, respiratory physiotherapy, respiratory therapy, and thoracic surgery. Two reviewers (J. O., E. W.) independently assessed which trials should be included. The literature search was limited to the English language. Abstracts in conference proceedings or unpublished sources were not included. Studies were excluded if the study population had undergone thoracic surgery via sternotomy. No exclusions were made in selected trials in consideration of the outcome measures chosen. The reviewers independently extracted the data on the type of surgery, methods of the study, types of intervention, and outcome.

Results
Of over 470 potentially eligible studies retrieved in the databases and reference lists, nally, six studies satised the inclusion criteria and were included in the review, as presented in the study ow chart (Fig. 1).1318 Four of the studies were performed on patients after an open abdominal surgery,13,14,16,17 and the remaining two following thoracic surgery performed through thoracotomy.15,18 The studies were published between 1979 and 1993 and were mainly performed in Scandinavia.13,1518 The PEP treatments were performed by a PEP-mask1518 or by a blow-bottle system.13,14 The evaluation period in the studies varied from the rst day after surgery to approximately 9 days post-operatively, and the number of patients included in the studies varied between 5016 and 160.18 The main characteristics of the studies are shown in Table 1. In four of the studies, PEP-mask treatment was compared with other breathing techniques: CPAP (1015 cmH2O),16,18 inspiratory resistance-positive expiratory pressure (IR-PEP), exact pressure not given,17,18 incentive spirometry,16 or placebo PEP (no resistance).15 In ve of the studies,1418 the evaluated PEP was given in addition to conventional chest physiotherapy. In the study by Heister*http://www.pedro.org.au/scale_item.html, last accessed 16 March

2009.

262

Positive expiratory pressure review

471 potentially relevant trials identified through electronic databases and reference lists

108 trials retrieved for more detailed evaluation

102 trials excluded, with reasons Guideline or review articles Non-RCT studies Surgery performed via sternotomy Pediatric sample Intubated patients Inspiratory muscle training (IMT) trials Positive end expiratory pressure (PEEP) trials Medical interventions Non-English-language Duplicate trials

23 full manuscripts reviewed for inclusion

14 trials potentially relevant

6 trials included in the systematic review

Fig. 1. Study ow chart.

Ricksten et al.16 compared PEP-mask treatment (1015 cmH2O), 30 breaths every waking hour, with CPAP and with a control group receiving basic physiotherapy with incentive spirometry. The alveolararteriolar oxygen difference was signicantly lower and PaO2 and forced vital capacity were signicantly higher compared to the control group on the second post-operative day. Furthermore, atelectatic consolidation was signicantly lower in the PEP group on the third post-operative day. In the study by Christensen et al.,17 no signicant differences were found between patients performing PEP-mask breathing (515 cmH2O) once per hour during daytime compared with a respiratory muscle-training group or a conventional physiotherapy group.17

berg et al.,13 the patients in the intervention group were requested to use PEP treatment only, without the specic physiotherapy treatment that was given to the control group. Atelectasis, evaluated in chest roentgenograms, was used as an outcome measure in all six studies, arterial blood gases (ABG) in four studies,1518 and pulmonary function measured by spirometry in four of the studies.14,1618 Other outcome measures used were temperature, expectoration,17,18 subjective experiences and time to chest tube removal,18 post-operative complications,14 alveolararteriolar oxygen difference16 and cough, dyspnoea, mobilisation, pain, use of bronchodilators, antibiotics, oxygen, pulse rate, and pulmonary auscultation.17

Thoracic surgery
Neither of the two studies evaluating PEP-mask treatment after thoracotomy showed any signicant effect of PEP compared with other treatments.15,18 Patients performing PEP-mask treatment for 10 min/h when awake during the daytime with an expiratory pressure of 10 cmH2O in the study by Frolund and Madsen15 did not show any positive effects on chest roentgenograms or ABG compared with a control group using a face-mask set without expiratory resistance. Ingwersen et al.18 showed that PEP-mask treatment (1015 cmH2O) 5 min/h awake after thoracotomy was comparable to CPAP or IRPEP treatment regarding the effects on lung volumes, ABG, and atelectatic consolidation.

Abdominal surgery
Of the four trials investigating PEP after abdominal surgery, two evaluated a blow-bottle device for expiratory pressure. In the study by Heisterberg et al.,13 conventional chest physiotherapy consisting of breathing exercises and postural drainage, with two daily visits by the physiotherapist, was compared with the blow-bottle technique, performed for 10 min every fourth hour. No signicant difference was found between the treatments regarding scoring of atelectasis. In the study by Campbell et al.,14 the addition of 20 breaths performed with a blow-bottle system (110 cmH2O) every second hour in addition to standard preand post-operative physiotherapy did not show any signicant improvements regarding post-operative pulmonary complications.

Methodological quality of the studies

The methodological quality assessment ranged from four points (low quality) on the PEDro scale14,17 to 56 points (medium quality),13,15,16,18 as reported in Table 2. No studies described a blinded therapist, but four studies used blinded assessors,13,15,16,18 and the study by Frolund and Madsen15 was the only one with blinded subjects. In no article was it reported whether the randomisation was concealed or not. All studies fullled the last criteria on the PEDro scale, point and variability measures.

Discussion
Of the six RCTs found investigating the effects of post-operative PEP, compared with other breathing techniques1518 or in addition to routine chest

263

 J. Orman and E. Westerdahl

Table 1
Characteristics of the included studies. Study Heisterberg13 Surgery/ subjects (n) Abdominal surgery 98 Groups and intervention PT* Blow bottle Treatment duration and frequency PT 30130 min/ day1self training twice/h for 5 days Blow bottle 10 min/4 h, daily reminder of PT for 5 days PT self-training/2 h Blow bottle 2 10 breaths/2 h Evaluation X-ray pre-op, 4 days Primary result No signicant difference

Campbell14

Abdominal surgery 71

PTw PTw1blow bottle 10 cmH2O (515)

Frolund15

Thoracic surgery 56

PTz1placebo PEP mask (no resistance) PTz1PEP mask 10 cmH2O (912)

PT twice/day Intervention 10 min/h awake daytime

Ricksten16

Abdominal surgery 43

PT1Trio PT1CPAP 1015 cmH2O PT1PEP mask 10 15 cmH2O

PT 3040 min twice/ day Trio, CPAP, PEP 30 breaths/h Started 1 h postoperative until day 3

Christensen17

Abdominal surgery 51

PTz PTz1PEP 5 15 cmH2O PTz1IR-PEP inspiration pressure tolerated 2 min/15 7 cmH2O

Ingwersen18

Thoracic surgery 144

PT k 1CPAP 15 cmH2O PT k 1PEP mask 1015 cmH2O PT k 1IR-PEP20 cmH2O/unknown

PT twice/day for 3 days PEP 1/h 510 breaths1huff pause, until expectoration stopped, for 3 days IR-PEP 1/h 510 breaths1huff pause, until expectoration stopped, for 3 days PT twice/day Mask 5 min/h

No signicant difference (higher PaO2in control group than PEP group 2 days, Po0.05) PEP: Lower [Aa]O2-diff, incidence of atelectasis 3 days (Po0.001), higher FVC (Po0.05) 3 days, higher PaO2 3 days (Po0.01) X-ray pre-op, 2 days, No signicant 3 days1when needed difference FEV1, FVC, FRC daily Subjective pain score, medicine, pulse rate, temperature, FiO2, ABG, mobilisation, dyspnoea registered daily X-ray, FVC% pre-op No signicant 2days, 4 days, 9 days difference ABG pre-op, 4 days, 9 days PaO2, temp, expectoration, exud chest tubes or time to removal, subjective

X-ray pre-op, if previous lung problems VC, FEV1 pre-op, 4 days Post-operative complications X-ray pre-op, rst night, 1 day, 4 days, 8 days1when needed or if complication was suspected ABG pre-op, 30 min after PT FVC, PEF pre-op, 3 days X-ray pre-op, 1 day, 3 days ABG pre-op, 6 h, 1 day, 2 days, 3 days [Aa]O2-diff calculated

No signicant difference

wInspiratory diaphragmatic and lateral costal breathing, hufng, and coughing in sitting position. If side lying was inadequate for secretions clearance postural drainage, tipping was added. zRapid mobilisation, walking exercises, arm exercises, coughing, diaphragm breathing. DBE, FET, active mobilisation. zDiaphragm breathing, pursed-lip breathing, hufngs in alternating positions. Mobilisation as early as possible. kGeneral information about chest PT and mask treatment. Diaphragm breathing, proper use of mask, FET, change of position, and early mobilisation day after operation. [Aa]O2-diff, alveolararteriolar oxygen difference; ABG, arterial blood gas; CPAP, continuous positive airway pressure; DBE, deep breathing exercise; FET, forced expiration technique; FEV1, forced expiratory volume 1 s; FRC, functional residual capacity; FVC, forced vital capacity; FVC%, forced vital capacity percent of vital capacity; IR-PEP, inspiratory resistance-positive expiratory pressure; PaCO2, partial pressure of carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood; PEP, positive expiratory pressure; PEF, peak expiratory ow; PPC, post-operative pulmonary complications; pre-op, pre-operatively; PT, physiotherapy; VC, vital capacity.

*Breathing exercises in supine and sitting positions, turning in bed, postural drainage, help in coughing.

264

Positive expiratory pressure review

physiotherapy treatment,13,14,17 only one study16 showed the effects of PEP. Ricksten et al.16 concluded that the PEP mask was better than incentive spirometry and as effective as CPAP with respect to preservation of lung volumes, oxygenation, and prevention of atelectasis. No trials were found evaluating PEP treatment in comparison with an untreated control group. All studies, even the placebo-controlled study by Frolund and Madsen,15 offered an active intervention with some kind of anticipated effect to control groups. Even if the pressure were low or missing, the device may change the breathing pattern and affect the outcome. The only PEP devices that were evaluated were the blow-bottle technique13,14 and the PEP mask system.1518 In clinical practice, there are several different devices available. The pursed-lip breathing technique and the utter technique, using a high-density ball creating an oscillation during expiration, have not been evaluated in this patient category. In a recent systematic review, it has been concluded that CPAP decrease the risk of postoperative complications after abdominal surgery6 and that it is more effective than deep breathing exercises in cardiac surgery patients.19 CPAP has also been shown to be more effective in preventing reintubation than IR-PEP in the study by Fagevik Olsen, but no comparison with PEP was made.20 The present results indicate that the PEP technique has an effect similar to that of other treatments such as CPAP16,18 and IR-PEP17,18 and that there is no evidence suggesting that PEP is inferior to other techniques. There is, however, a lack of evidence for PEP conferring an added benet when used in combination with other physiotherapy modalities. Compared with routine chest physiotherapy, no additional effects of PEP were described in the trials.13,14,17 It is obvious that there is a need for more evaluation to verify the benet of the treatment. Possibly there are positive effects, but they have not yet been proven. Several of the included studies were of a lower methodological quality, according to the internal validity score of the PEDro scale. One of the reasons for this could be that the studies were published many years ago. Because publications in this area are scarce, we decided not to restrict the inclusion of trials by year of publication. The PEP technique can be used both to decrease and to increase lung volumes.10 If the goal is to improve post-operative pulmonary function, a large and sustained deep breath is important to

*The methodological quality for internal validity and statistical information was assessed by PEDro score. The studies achieved one score for each fullled criterion. The individual

Methodological quality of studies as assessed by the Physiotherapy Evidence Database (PEDro) scale.

Heisterberg13 Campbell14 Frolund15 Ricksten16 Christensen17 Ingwersen18

Table 2

Study

criteria were marked as: yes (positive) or no (negative). Data were considered missing if they were not mentioned explicitly in the text. Studies with a score of 5 or more on the PEDro scale were considered to be of moderate or high quality.

Total score Point and variability measures Betweengroup comparisons Intentionto-treat analyses Adequate follow-up Blind assessors Blind therapists Blind subjects Baseline comparability Concealed allocation Random allocation Eligibility criteria

Yes No Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes

No No No NO No No

No No Yes Yes Yes Yes

No No Yes No No No

No No No No No No

Yes No Yes Yes No Yes

Yes Yes No Yes No Yes

No No No No No No

Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes

5/10* 4/10 6/10* 6/10* 4/10 6/10*

265

 J. Orman and E. Westerdahl

obtain effect from the PEP treatment.21 The theoretical basis of the technique is that PEP increases FRC.22,23 The instructions to the patient on how to perform the technique were not very well described in the trials. If no maximal inspirations were achieved, this could possibly explain why no effects on atelectasis were shown, although chest roentgenograms were used as outcome measures in all the trials included. Deep breathing exercises performed with no mechanical device may prove as effective as treatment with a PEP device after abdominal and thoracic surgery, but to date, this has not been studied. In this study, different modalities of PEP, with diverse duration and pressure and different administration of the breathing exercises, have been reviewed. Today there is no agreement on the optimal training intensity recommended for the patient, and perhaps the given treatment duration and frequency in the included trials were not the best possible. Optimal pain relief, and instructions on how and when to perform the breathing exercises are essential, as are early mobilisation and an upright position. Exclusion of trials published in languages other than English might be considered a bias, but the PEP technique is not yet a treatment technique that is used worldwide. So far, the technique is mostly used in European countries, although it has started to be familiar in other countries. Only one of the studies was performed outside Scandinavia.14 It is a challenge to evaluate methodological quality. The criteria are not listed in order of precedence, and neither does the scale take the size of the studies or the effect size of the intervention into account, which can be considered a shortcoming. Four of the trials in this review had a score of 5 or more,13,15,16,18 although the articles were published at an early date. In light of this, the reviewed articles represent a fairly good quality, considering that the quality has increased over time.12 Earlier trials often do not state whether treatment allocation was concealed and how, in detail, allocation was performed. To blind the patients as well as care providers is often impossible. In this review, none of the included trials presented any sample size calculations and statistical analysis was not very well described. The signicance of prophylactic chest physiotherapy, especially after low-risk surgery, has been questioned.4,5 Breathing exercises with PEP are provided routinely for patients following surgery, although no obvious effect of this method has

been distinguished in the prevention of pulmonary complications. Fully randomized and controlled studies with large materials are needed to verify the treatment. Hopefully, this review will stimulate new research to increase knowledge of the treatment. The treatment effects of PEP were only evaluated during the rst post-operative days, and especially long-term treatment evaluations are needed.

Conclusion
In this review, only one of the six included trials showed any positive effects of PEP compared with other physiotherapy breathing techniques. According to this result, the effect of the treatment is uncertain, and new research must be performed to draw any conclusions about the effects of PEP treatment in patients undergoing abdominal or thoracic surgery.

References
1. Serejo LG, da Silva-Junior FP, Bastos JP, de Bruin GS, Mota RM, de Bruin PF. Risk factors for pulmonary complications after emergency abdominal surgery. Respir Med 2007; 101: 80813. 2. Warner DO. Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology 2000; 92: 146772. 3. Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006; 144: 596608. 4. Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. Br J Surg 1997; 84: 15358. 5. Pasquina P, Tramer MR, Granier JM, Walder B. Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. Chest 2006; 130: 188799. 6. Ferreyra GP, Baussano I, Squadrone V, Richiardi L, Marchiaro G, Del Sorbo L, Mascia L, Merletti F, Ranieri VM. Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg 2008; 247: 61726. 7. Mahlmeister MJ, Fink JB, Hoffman GL, Fifer LF. Positiveexpiratory-pressure mask therapy: theoretical and practical considerations and a review of the literature. Respir Care 1991; 36: 121829. 8. Pryor JA, Prasad SA. Physiotherapy for respiratory and cardiac problems, adults and paediatrics, 3rd edn. Edinburgh: Churchill Livingstone, 2002. 9. Elkins MR, Jones A, van der Schans C. Positive expiratory pressure physiotherapy for airway clearance in people with cystic brosis. Cochrane Database Syst Rev 2006: CD003147.

266

Positive expiratory pressure review

10. Fagevik Olsen M, Westerdahl E. Positive expiratory pressure in patients with chronic obstructive pulmonary disease a systematic review. Respiration 2009; 77: 1108. 11. Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Bouter LM, Knipschild PG. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol 1998; 51: 123541. 12. Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother 2002; 48: 439. 13. Heisterberg L, Johansen TS, Larsen HW, Holm M, Andersen B. Postoperative pulmonary complications in upper abdominal surgery. A randomized clinical comparison between physiotherapy and blow-bottles. Acta Chir Scand 1979; 145: 5057. 14. Campbell T, Ferguson N, McKinlay RG. The use of a simple self-administered method of positive expiratory pressure (PEP) in chest physiotherapy after abdominal surgery. Physiotherapy 1986; 72: 498500. 15. Frolund L, Madsen F. Self-administered prophylactic postoperative positive expiratory pressure in thoracic surgery. Acta Anaesthesiol Scand 1986; 30: 3815. 16. Ricksten SE, Bengtsson A, Soderberg C, Thorden M, Kvist H. Effects of periodic positive airway pressure by mask on postoperative pulmonary function. Chest 1986; 89: 77481. 17. Christensen EF, Schultz P, Jensen OV, Egebo K, Engberg M, Gron I, Juhl B. Postoperative pulmonary complications and lung function in high-risk patients: a comparison of three physiotherapy regimens after upper abdominal surgery in general anesthesia. Acta Anaesthesiol Scand 1991; 35: 97104. 18. Ingwersen UM, Larsen KR, Bertelsen MT, Kiil-Nielsen K, Laub M, Sandermann J, Bach K, Hansen H. Three different mask physiotherapy regimens for prevention of postoperative pulmonary complications after heart and pulmonary surgery. Intensive Care Med 1993; 19: 2948. 19. Matte P, Jacquet L, Van Dyck M, Goenen M. Effects of conventional physiotherapy, continuous positive airway pressure and non-invasive ventilatory support with bilevel positive airway pressure after coronary artery bypass grafting. Acta Anaesthesiol Scand 2000; 44: 7581. 20. Fagevik Olsen M, Wennberg E, Johnsson E, Josefson K, Lonroth H, Lundell L. Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques. Br J Surg 2002; 89: 122834. 21. Colgan FJ, Mahoney PD, Fanning GL. Resistance breathing (blow bottles) and sustained hyperinations in the treatment of atelectasis. Anesthesiology 1970; 32: 54350. 22. Lumb AB. Nunns applied respiratory physiology, 5th edn. Oxford: Butterworth-Heinemann, 2000. 23. Heitz M, Holzach P, Dittmann M. Comparison of the effect of continuous positive airway pressure and blowing bottles on functional residual capacity after abdominal surgery. Respiration 1985; 48: 27784. Address: Jenny Orman Department of Intensive Care Linkoping University Hospital SE-581 85 Linkoping Sweden e-mail: jenny.orman@lio.se

267