Effectiveness of I COUGH Program to Dyspnea, Respiratory Parameters, Mobility and Pain After Major Abdominal Surgery

Pain Clinical Trial

Official title:

The Effectiveness of The "I Cough" Care Program to Dyspnea, Respiratory Parameters, Mobility and Pain After Major Abdominal Surgery.

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT06255327
• Other study ID #: YTU.PT.TH.01/2023
• Status: Completed
• Phase: N/A
• Start date: December 26, 2023
• Est. completion date: January 10, 2024

Study information

• Verified date: May 2024
• Source: Yeditepe University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The purpose of the current study was to investigate the effect of the I COUGH care program following major abdominal surgery dyspnea, oxygen saturation, pulmonary function, mobility, and pain after major abdominal surgery (MAS), participants were subjected to the "I COUGH" care program designed to support their health condition and reduce complications. The study aimed to investigate a simple and inexpensive pulmonary care program that can be easily understood and remembered by patients, their families, and medical staff. Ho: The I COUGH care program after MAS does not improves pulmonary functions, oxygen saturation, mobility and decrease dyspnea and pain after MAS. H1: The I COUGH care program improves pulmonary functions, oxygen saturation mobility and decrease dyspnea and pain after MAS.

Description:

A total of 60 adult individuals aged between 30 and 60 years (mean age of 39.9±8.82) comprising 13 males and 47 females underwent major abdominal surgery requiring general anesthesia and hospitalization were invited to study. Patients were randomly assigned to either the Control Group (CG, n=30) or the Experimental Group (EG, n=30) using the block randomization method. Patients in the EG participated in the I COUGH care program included flow-incentive spirometer, oral care, coughing and breathing exercises, patient, and family education, getting out of bed, and elevating the head of the bed by more than 30 degrees for 3 days post-surgery. The patients in the CG did not undergo any interventions. All participants were assessed in terms of vital signs as heart rate, blood pressure, respiratory rate, and oxygen saturation. Moreover, dyspnea was assessed using the Modified Borg dyspnea Scale, pulmonary functions were evaluated using spirometry, mobility was assessed by Activity and Mobility Promotion scale and pain assessed Visual Analog Scale. Data were collected from all patients at baseline 10 h after the first day of surgery and on the day of discharge from the hospitals. The findings of the present study revealed that the I COUGH care program effectively improved pulmonary function and blood oxygenation, reduced the incidence of dyspnea, increased mobility, and decreased postoperative pain, with a statistically significant difference between the experimental and control groups (p<0.05).

Recruitment information / eligibility

• Status: Completed
• Enrollment: 60
• Est. completion date: January 10, 2024
• Est. primary completion date: January 5, 2024
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 30 Years to 60 Years

Eligibility

Inclusion Criteria:

• Volunteering to participate in the study.
• Eligible patients are adults of both sexes between 30-60 years (Through the study, we are trying to reduce the variance and confounding factors that may arise from including patients who are less than 30 years old due to different stages of growth, physical abilities, hormonal levels, etc., or over 60 years old due to the prevalence of chronic diseases or diseases associated with aging).
• Patients underwent elective abdominal surgery that required general anaesthesia and hospital stay e.g., Hernia repair, gall bladder removal, exploratory laparotomy, morbid obesity, ovarian cyst, Sigmoid diverticulitis, appendicitis, or other abdominal cavity procedures performed by laparoscopy and conventional laparotomy with a 5 cm or less incision above or extending above the umbilicus. (Incisions > 5cm may affect on possible results might be impacted in terms of: Increased risk of infection, risk of bleeding, pain, and discomfort during ambulation).

Exclusion Criteria:

• The patient complains of an unstable heart rate or cardiac condition.
• Symptomatic heart failure, unstable angina.
• Pulmonary Hypertension
• Unstable hypertension
• The patient underwent organ transplants.
• The patient presented an aneurysm of any arterial segment.
• Serious condition or transferred to the intensive care unit after surgery.
• Severe nephropathy.
• A patient with cancer.
• Cerebrovascular accident / Stroke.
• Patient with balance or vestibular disorder.

Related Conditions & MeSH terms

• Dyspnea
• Mobility Limitation
• Pain
• Respiratory Insufficiency

Intervention

Other:
• I COUGH care program
The I COUGH program, initiated 10 hours after surgery, emphasizes the following elements: Incentive spirometry: Encouraging patients to use the Flow-IS device ten times every two hours for three days. Coughing and deep breathing: Participants should perform 3-5 coughs and deep breaths every 2 hours for 3 days. Oral care: Brushing teeth and using mouthwash twice daily between 8:00 a.m. and 8:00 p.m. Mouth brushes should be sterile, and non-alcoholic mouthwash is recommended. Understanding (education): Patients and their relatives receive instructions on the care program and steps to follow. Getting out of bed: Patients are encouraged to sit in a chair at least once and walk at least 3 times per day in the room and corridor with assistance as needed. Head-of-bed elevation: Keeping the head of the bed elevated more than 30 degrees.

Locations

Country	Name	City	State
Libyan Arab Jamahiriya	AL-ASSEMA Hospital	Tripoli
Libyan Arab Jamahiriya	AL-KHALIL Hospital	Tripoli
Libyan Arab Jamahiriya	ROYAL Clinic	Tripoli

Sponsors (1)

Lead Sponsor	Collaborator
Yeditepe University

Country where clinical trial is conducted

Libyan Arab Jamahiriya, 

References & Publications (54)

Banerjee D, Kamuren J, Baird GL, Palmisciano A, Krishnan I, Whittenhall M, Klinger JR, Ventetuolo CE. The Modified Borg Dyspnea Scale does not predict hospitalization in pulmonary arterial hypertension. Pulm Circ. 2017 Apr-Jun;7(2):384-390. doi: 10.1177/2045893217695568. Epub 2017 Mar 16. — View Citation

Boden I, Skinner EH, Browning L, Reeve J, Anderson L, Hill C, Robertson IK, Story D, Denehy L. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ. 2018 Jan 24;360:j5916. doi: 10.1136/bmj.j5916. Erratum In: BMJ. 2019 Apr 25;365:l1862. — View Citation

Branson RD. The scientific basis for postoperative respiratory care. Respir Care. 2013 Nov;58(11):1974-84. doi: 10.4187/respcare.02832. — View Citation

Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal surgery. Chest. 1997 Mar;111(3):564-71. doi: 10.1378/chest.111.3.564. — View Citation

Browning L, Denehy L, Scholes RL. The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Aust J Physiother. 2007;53(1):47-52. doi: 10.1016/s0004-9514(07)70061-2. — View Citation

Cassidy MR, Rosenkranz P, Macht RD, Talutis S, McAneny D. The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience. Jt Comm J Qual Patient Saf. 2020 May;46(5):241-249. doi: 10.1016/j.jcjq.2020.01.005. Epub 2020 Jan 30. — View Citation

Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013 Aug;148(8):740-5. doi: 10.1001/jamasurg.2013.358. — View Citation

Cheifetz O, Lucy SD, Overend TJ, Crowe J. The effect of abdominal support on functional outcomes in patients following major abdominal surgery: a randomized controlled trial. Physiother Can. 2010 Summer;62(3):242-53. doi: 10.3138/physio.62.3.242. Epub 2010 Jul 23. — View Citation

Crisafulli E, Clini EM. Measures of dyspnea in pulmonary rehabilitation. Multidiscip Respir Med. 2010 Jun 30;5(3):202-10. doi: 10.1186/2049-6958-5-3-202. — View Citation

Davies SJ, Francis J, Dilley J, Wilson RJ, Howell SJ, Allgar V. Measuring outcomes after major abdominal surgery during hospitalization: reliability and validity of the Postoperative Morbidity Survey. Perioper Med (Lond). 2013 Feb 4;2(1):1. doi: 10.1186/2047-0525-2-1. — View Citation

Delgado DA, Lambert BS, Boutris N, McCulloch PC, Robbins AB, Moreno MR, Harris JD. Validation of Digital Visual Analog Scale Pain Scoring With a Traditional Paper-based Visual Analog Scale in Adults. J Am Acad Orthop Surg Glob Res Rev. 2018 Mar 23;2(3):e088. doi: 10.5435/JAAOSGlobal-D-17-00088. eCollection 2018 Mar. — View Citation

Delgado HR, Braun SR, Skatrud JB, Reddan WG, Pegelow DF. Chest wall and abdominal motion during exercise in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis. 1982 Aug;126(2):200-5. doi: 10.1164/arrd.1982.126.2.200. — View Citation

do Nascimento Junior P, Modolo NS, Andrade S, Guimaraes MM, Braz LG, El Dib R. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev. 2014 Feb 8;2014(2):CD006058. doi: 10.1002/14651858.CD006058.pub3. — View Citation

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 Nov;84(11):1535-8. doi: 10.1111/j.1365-2168.1997.02828.x. — View Citation

Grams ST, Ono LM, Noronha MA, Schivinski CI, Paulin E. Breathing exercises in upper abdominal surgery: a systematic review and meta-analysis. Rev Bras Fisioter. 2012 Sep-Oct;16(5):345-53. doi: 10.1590/s1413-35552012005000052. Epub 2012 Oct 9. — View Citation

Hall JC, Tarala RA, Tapper J, Hall JL. Prevention of respiratory complications after abdominal surgery: a randomised clinical trial. BMJ. 1996 Jan 20;312(7024):148-52; discussion 152-3. doi: 10.1136/bmj.312.7024.148. — View Citation

Hedenstierna G, Rothen HU. Respiratory function during anesthesia: effects on gas exchange. Compr Physiol. 2012 Jan;2(1):69-96. doi: 10.1002/cphy.c080111. — View Citation

Jammer I, Wickboldt N, Sander M, Smith A, Schultz MJ, Pelosi P, Leva B, Rhodes A, Hoeft A, Walder B, Chew MS, Pearse RM; European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM); European Society of Anaesthesiology; European Society of Intensive Care Medicine. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol. 2015 Feb;32(2):88-105. doi: 10.1097/EJA.0000000000000118. — View Citation

Katz S, Arish N, Rokach A, Zaltzman Y, Marcus EL. The effect of body position on pulmonary function: a systematic review. BMC Pulm Med. 2018 Oct 11;18(1):159. doi: 10.1186/s12890-018-0723-4. — View Citation

Kumar AS, Alaparthi GK, Augustine AJ, Pazhyaottayil ZC, Ramakrishna A, Krishnakumar SK. Comparison of Flow and Volume Incentive Spirometry on Pulmonary Function and Exercise Tolerance in Open Abdominal Surgery: A Randomized Clinical Trial. J Clin Diagn Res. 2016 Jan;10(1):KC01-6. doi: 10.7860/JCDR/2016/16164.7064. Epub 2016 Jan 1. — View Citation

Lawrence VA, Cornell JE, Smetana GW; American College of Physicians. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006 Apr 18;144(8):596-608. doi: 10.7326/0003-4819-144-8-200604180-00011. — View Citation

Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med. 1995 Dec;10(12):671-8. doi: 10.1007/BF02602761. — View Citation

Louie A, Feiner JR, Bickler PE, Rhodes L, Bernstein M, Lucero J. Four Types of Pulse Oximeters Accurately Detect Hypoxia during Low Perfusion and Motion. Anesthesiology. 2018 Mar;128(3):520-530. doi: 10.1097/ALN.0000000000002002. — View Citation

Manzano RM, Carvalho CR, Saraiva-Romanholo BM, Vieira JE. Chest physiotherapy during immediate postoperative period among patients undergoing upper abdominal surgery: randomized clinical trial. Sao Paulo Med J. 2008 Sep;126(5):269-73. doi: 10.1590/s1516-31802008000500005. — View Citation

McLaughlin KH, Friedman M, Hoyer EH, Kudchadkar S, Flanagan E, Klein L, Daley K, Lavezza A, Schechter N, Young D; JH-AMP Group. The Johns Hopkins Activity and Mobility Promotion Program: A Framework to Increase Activity and Mobility Among Hospitalized Patients. J Nurs Care Qual. 2023 Apr-Jun 01;38(2):164-170. doi: 10.1097/NCQ.0000000000000678. Epub 2022 Dec 3. — View Citation

Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017 Mar 1;118(3):317-334. doi: 10.1093/bja/aex002. — View Citation

Moore JA, Conway DH, Thomas N, Cummings D, Atkinson D. Impact of a peri-operative quality improvement programme on postoperative pulmonary complications. Anaesthesia. 2017 Mar;72(3):317-327. doi: 10.1111/anae.13763. Epub 2017 Jan 4. — View Citation

Nafiu OO, Ramachandran SK, Ackwerh R, Tremper KK, Campbell DA Jr, Stanley JC. Factors associated with and consequences of unplanned post-operative intubation in elderly vascular and general surgery patients. Eur J Anaesthesiol. 2011 Mar;28(3):220-4. doi: 10.1097/EJA.0b013e328342659c. — View Citation

Nishikawa M, Honda M, Kimura R, Kobayashi A, Yamaguchi Y, Hori S, Kobayashi H, Waragai M, Kawamura H, Nakayama Y, Todate Y, Takano Y, Yamaguchi H, Hamada K, Iketani S, Seto I, Izumi Y, Seto K. The bacterial association with oral cavity and intra-abdominal abscess after gastrectomy. PLoS One. 2020 Nov 9;15(11):e0242091. doi: 10.1371/journal.pone.0242091. eCollection 2020. — View Citation

O'Neill S, McCarthy DS. Postural relief of dyspnoea in severe chronic airflow limitation: relationship to respiratory muscle strength. Thorax. 1983 Aug;38(8):595-600. doi: 10.1136/thx.38.8.595. — View Citation

Odor PM, Bampoe S, Gilhooly D, Creagh-Brown B, Moonesinghe SR. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ. 2020 Mar 11;368:m540. doi: 10.1136/bmj.m540. — View Citation

Pasquina P, Tramer MR, Granier JM, Walder B. Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. Chest. 2006 Dec;130(6):1887-99. doi: 10.1378/chest.130.6.1887. — View Citation

Restrepo RD, Wettstein R, Wittnebel L, Tracy M. Incentive spirometry: 2011. Respir Care. 2011 Oct;56(10):1600-4. doi: 10.4187/respcare.01471. — View Citation

Rowley DD, Malinowski TP, Di Peppe JL, Sharkey RM, Gochenour DU, Enfield KB. A Randomized Controlled Trial Comparing Two Lung Expansion Therapies After Upper Abdominal Surgery. Respir Care. 2019 Oct;64(10):1181-1192. doi: 10.4187/respcare.06812. Epub 2019 May 21. — View Citation

Sabate S, Mazo V, Canet J. Predicting postoperative pulmonary complications: implications for outcomes and costs. Curr Opin Anaesthesiol. 2014 Apr;27(2):201-9. doi: 10.1097/ACO.0000000000000045. — View Citation

Sharp JT, Drutz WS, Moisan T, Foster J, Machnach W. Postural relief of dyspnea in severe chronic obstructive pulmonary disease. Am Rev Respir Dis. 1980 Aug;122(2):201-11. doi: 10.1164/arrd.1980.122.2.201. No abstract available. — View Citation

Siafakas NM, Mitrouska I, Bouros D, Georgopoulos D. Surgery and the respiratory muscles. Thorax. 1999 May;54(5):458-65. doi: 10.1136/thx.54.5.458. No abstract available. — View Citation

Silva YR, Li SK, Rickard MJ. Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial. Physiotherapy. 2013 Sep;99(3):187-93. doi: 10.1016/j.physio.2012.09.006. Epub 2012 Dec 1. — View Citation

Smetana GW. Postoperative pulmonary complications: an update on risk assessment and reduction. Cleve Clin J Med. 2009 Nov;76 Suppl 4:S60-5. doi: 10.3949/ccjm.76.s4.10. — View Citation

Smith PR, Baig MA, Brito V, Bader F, Bergman MI, Alfonso A. Postoperative pulmonary complications after laparotomy. Respiration. 2010;80(4):269-74. doi: 10.1159/000253881. Epub 2009 Oct 28. — View Citation

So MW, Heo HM, Koo BS, Kim YG, Lee CK, Yoo B. Efficacy of incentive spirometer exercise on pulmonary functions of patients with ankylosing spondylitis stabilized by tumor necrosis factor inhibitor therapy. J Rheumatol. 2012 Sep;39(9):1854-8. doi: 10.3899/jrheum.120137. Epub 2012 Aug 1. — View Citation

Souza Possa S, Braga Amador C, Meira Costa A, Takahama Sakamoto E, Seiko Kondo C, Maida Vasconcellos AL, Moran de Brito CM, Pereira Yamaguti W. Implementation of a guideline for physical therapy in the postoperative period of upper abdominal surgery reduces the incidence of atelectasis and length of hospital stay. Rev Port Pneumol. 2014 Mar-Apr;20(2):69-77. doi: 10.1016/j.rppneu.2013.07.005. Epub 2013 Nov 27. — View Citation

Spadaro S, Caramori G, Rizzuto C, Mojoli F, Zani G, Ragazzi R, Valpiani G, Dalla Corte F, Marangoni E, Volta CA. Expiratory Flow Limitation as a Risk Factor for Pulmonary Complications After Major Abdominal Surgery. Anesth Analg. 2017 Feb;124(2):524-530. doi: 10.1213/ANE.0000000000001424. — View Citation

Spahija J, Marchie Md, Ghezzo H, Grassino A. Factors discriminating spontaneous pursed-lips breathing use in patients with COPD. COPD. 2010 Aug;7(4):254-61. doi: 10.3109/15412555.2010.496820. — View Citation

Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WD, Pitta F, Sewell L, Raskin J, Bourbeau J, Crouch R, Franssen FM, Casaburi R, Vercoulen JH, Vogiatzis I, Gosselink R, Clini EM, Effing TW, Maltais F, van der Palen J, Troosters T, Janssen DJ, Collins E, Garcia-Aymerich J, Brooks D, Fahy BF, Puhan MA, Hoogendoorn M, Garrod R, Schols AM, Carlin B, Benzo R, Meek P, Morgan M, Rutten-van Molken MP, Ries AL, Make B, Goldstein RS, Dowson CA, Brozek JL, Donner CF, Wouters EF; ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013 Oct 15;188(8):e13-64. doi: 10.1164/rccm.201309-1634ST. Erratum In: Am J Respir Crit Care Med. 2014 Jun 15;189(12):1570. — View Citation

Sullivan KA, Churchill IF, Hylton DA, Hanna WC. Use of Incentive Spirometry in Adults following Cardiac, Thoracic, and Upper Abdominal Surgery to Prevent Post-Operative Pulmonary Complications: A Systematic Review and Meta-Analysis. Respiration. 2021;100(11):1114-1127. doi: 10.1159/000517012. Epub 2021 Jul 16. — View Citation

Sum SK, Peng YC, Yin SY, Huang PF, Wang YC, Chen TP, Tung HH, Yeh CH. Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: a randomized controlled trial. Trials. 2019 Dec 30;20(1):797. doi: 10.1186/s13063-019-3943-x. — View Citation

Tazreean R, Nelson G, Twomey R. Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements. J Comp Eff Res. 2022 Feb;11(2):121-129. doi: 10.2217/cer-2021-0258. Epub 2022 Jan 20. — View Citation

Thomas JA, McIntosh JM. Are incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery? A systematic overview and meta-analysis. Phys Ther. 1994 Jan;74(1):3-10; discussion 10-6. doi: 10.1093/ptj/74.1.3. — View Citation

Tyson AF, Kendig CE, Mabedi C, Cairns BA, Charles AG. The effect of incentive spirometry on postoperative pulmonary function following laparotomy: a randomized clinical trial. JAMA Surg. 2015 Mar 1;150(3):229-36. doi: 10.1001/jamasurg.2014.1846. — View Citation

Weindler J, Kiefer RT. The efficacy of postoperative incentive spirometry is influenced by the device-specific imposed work of breathing. Chest. 2001 Jun;119(6):1858-64. doi: 10.1378/chest.119.6.1858. — View Citation

Weller WE, Rosati C. Comparing outcomes of laparoscopic versus open bariatric surgery. Ann Surg. 2008 Jul;248(1):10-5. doi: 10.1097/SLA.0b013e31816d953a. — View Citation

Westwood K, Griffin M, Roberts K, Williams M, Yoong K, Digger T. Incentive spirometry decreases respiratory complications following major abdominal surgery. Surgeon. 2007 Dec;5(6):339-42. doi: 10.1016/s1479-666x(07)80086-2. — View Citation

Wren SM, Martin M, Yoon JK, Bech F. Postoperative pneumonia-prevention program for the inpatient surgical ward. J Am Coll Surg. 2010 Apr;210(4):491-5. doi: 10.1016/j.jamcollsurg.2010.01.009. — View Citation

* Note: There are 54 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Heart Rate (HR)	The number of heart beats per minute.	3 days of postoperatively
Primary	Systolic Blood pressure (SBP)	The minimum pressure recorded just prior to the next contraction.	3 days of postoperatively
Primary	Diastolic Blood pressure (DBP)	The maximum blood pressure during contraction of the ventricles.	3 days of postoperatively
Primary	Respiratory Rate (RR)	The number of breaths they take per minute.	3 days of postoperatively
Primary	Oxygen Saturation (SPO2)	A pulse oximeter reading that indicates what percentage of your blood is saturated.	3 days of postoperatively
Primary	Modified Borg Dyspnea Scale (MBDS)	A valid and reliable tool to measure the intensity of dyspnea. It is a categorical scale with ratio properties, rating from 0 to 10, 0 being not dyspneic at all and 10 being maximally dyspneic.	3 days of postoperatively
Primary	Pulmonary Function Test FVC	Noninvasive test that show how well the lungs are working, measuring of FVC	3 days of postoperatively
Primary	Pulmonary Function Test FEV	Noninvasive tests that show how well the lungs are working, measuring of FEV	3 days of postoperatively
Primary	Pulmonary Function Test FEV1/FVC	Noninvasive tests that show how well the lungs are working, measuring of FEV1/FVC	3 days of postoperatively
Primary	Pulmonary Function Test PEFR	Noninvasive tests that show how well the lungs are working, measuring of PEFR.	3 days of postoperatively
Primary	Activity and Mobility Promotion (AMP)	AMP is based on measuring increasing patient mobility during hospital stay. The initial goals of this program included mobilization of each patient 3 times per day, documentation of patient mobility levels on the AMP scale.	3 days of postoperatively
Primary	Visual Analogue Scale (VAS)	This measure is based on self-reported symptoms and is recorded with a single mark placed along a 10-cm line, which represents a continuum between "no pain" on the left end (0 cm) and "worst pain" on the right end. to determine the intensity of pain and its enhancement when coughing in the postoperative area.	3 days of postoperatively