Thoracic Surgery Patients Research Articles

Thoracic and cardiovascular surgery patients: Intensive care unit experiences

Intensive care units are stressful places where patients experience physical and psychological discomfort. Understanding the experience of these patients regarding nursing care is very important. To determine the intensive care experiences of thoracic and cardiovascular surgery patients and the factors that affect them. The research consists of two phases: quantitative and qualitative. This was a descriptive and cross-sectional study. Its research sample comprised 100 patients who spent at least one night in an intensive care unit after thoracic or cardiovascular surgery. The Intensive Care Experiences Scale (ICES) and the Numeric Rating Scale were used. Two open-ended questions were asked to the patients to understand what they felt when they were attached to mechanical ventilation and to describe their intensive care experiences. The ICES mean score was 66.35 ± 6.88. Significant negative relationships were found between length of stay and severity of pain and ICES total scores. A significant difference was found between scale scores and being understood by health care professionals when attached to mechanical ventilation. The patients stated that, when they were attached to mechanical ventilation and during their stay in the intensive care unit, they experienced feelings of helplessness, uncertainty, and fear. They also experienced physical discomfort and reported no longer fearing death. It was determined that patients partially positively perceived their experiences. It was found that they focused on coming out of surgery alive. The physical discomfort and negative emotions reported can be reduced or relieved by competent care. The intensive care experiences and emotions of intensive care patients are important. Physical discomfort and negative emotions can be mitigated or alleviated by competent nursing care.

Apneic oxygenation in thoracic surgery in patients with previous pneumonectomy

Introduction Anaesthetic management of patients undergoing thoracic surgical procedures for lung cancer poses unique challenges to the anaesthesiologist, including patients’ comorbidities, lateral decubitus position, the need for lung isolation, and the associated pathophysiology during and after these procedures. Anaesthetic management is even more challenging in patients with previous pneumonectomy. In this case report we present two patients, who had a previous history of left pneumonectomy and were scheduled for surgical resection of a tumor in the remaining right lung. Methods Apneic oxygenation was used in both patients (patients A and B) intraoperatively, initially by oxygen insufflation via a thin catheter advanced to the level of the carina through a single lumen endotracheal tube. After the development of hypoxemia apneic oxygenation was continued via a Mapleson C circuit. Results For a significant period of time, oxygenation was preserved in both patients. Patients A and B showed time to oxygen desaturation of 30min and 25min respectively. Hypoxemia was recognized immediately by SpO2 decline below 90% and was confirmed via blood gas samples. Apneic oxygenation via a Mapleson C circuit was applied successfully for hypoxemia management in both patients. Oxygen levels improved immediately and remained stable until the end of apneic oxygenation. Total duration of apneic oxygenation was 90min and 50min in patients A and B, respectively. Increase of arterial carbon dioxide tension (PaCO2) and subsequent respiratory acidosis were predictable results of apneic oxygenation that were corrected quickly by mechanical ventilation (MV). After the end of surgery, both patients were admitted intubated to the ICU, where weaning from MV was successful after 2hrs. Patients A and B were discharged from the ICU on first postoperative day after an uncomplicated postoperative course. Discussion Apneic oxygenation is an acceptable oxygenation technique during thoracic surgery, especially in patients with previous pneumonectomy, which is able to keep sufficient oxygenation for a significant period of time, and does not deserve any special equipment. The expected hypercapnia and respiratory acidosis limit the duration of its application. PaCO2 values are related with the total time of apneic oxygenation and the only effective way for its decrease is mechanical ventilation. In the absence of pulmonary hypertension or pathology of the brain, mechanical ventilation normalises PaCO2 and pH quickly, without any complications.

Retrospective evaluation of the use of left sided double-lumen endobronchial tubes with an embedded camera VivaSight-DL® during lung separation in 30 thoracic surgery patients

Introduction Lung isolation is essential in thoracic surgery, specially to achieve a lung resection. Left sided double-lumen endobronchial tubes with an embedded camera (VTDL) VivaSight-DL® allow the airway's management and its continuous visualization on a portable external monitor as well as one-lung isolation during anesthetics procedures1. It might be useful in thoracic surgery. Although nowadays the fiberoptic bronchoscopy (FBS) is the “gold standard” to verify the position of endobronchial tubes, the VTDL might become an alternative2. The purpose of this study is to review whether the VTDL reduces or overrides the need for FBS for verification of the endobronchial tube's placement during intubation. Methods Retrospective descriptive and longitudinal study during 14,5 months in the CHGUV for patients who underwent lung resection procedures with VTDL VivaSight-DL® for one-lung isolation. Data collected included: sex, age, body mass index, Mallampati, Cormack-Lehane, ASA risk, difficult intubation, airway's management, FBS use, VTDL size, PEEP, SpO2, FiO2, ETCO2, peak flow, hospital stay, complications, re-admission and mortality. Results 30 patients who underwent lung resection procedures using VTDL were included. The age average was 66’27± 1,65 years. The VTDL was used with direct laryngoscope. Neither of them needed FBS. The intraoperative respiratory parameters were optimal (Fig. 1. TLV: two lung ventilation, OLV: one lung ventilation). The average time of stay in ICU was 1,41 ± 0,45 days and the total hospital stay 6,23 ± 0,83 days. There was 1 re-admission in ICU, 2 in hospital and 11 complications. Survival rate was 100%. Discussion Lung isolation is very important in thoracic surgery. Left sided double-lumen endobronchial tubes with an embedded camera (VTDL) VivaSight-DL® allow the airway's management and its continuous visualization on a portable external monitor as well as one-lung isolation during anesthetics procedures1. It might be useful in thoracic surgery because some studies concludes that this device is useful to check the double lumen insertion and its displacements during the changes of position of the thoracic patients or during the thoracic surgical procedure 2. Perhaps the FBS is now no so necessary as in the past but we needed more studies to analyze this situation.

Myocardial Injury After Noncardiac Surgery: Incidence, Predictive Factors, and Outcome in High-Risk Patients Undergoing Thoracic Surgery: An Observational Study

The authors aimed to evaluate the incidence of myocardial injury after noncardiac surgery (MINS), its relationship with perioperative variables, and its prognostic implications for 30-day mortality in high-risk thoracic surgery patients. Observational study including cardiovascular high-risk patients undergoing routine postoperative troponin monitoring during the first 2 postoperative days. MINS was diagnosed based on at least 1 troponin I determination ≥0.04 ng/mL with no evidence of a nonischemic etiology. Tertiary university hospital. Adult patients with cardiac risk factors, defined as patients ≥65 years old or patients <65 years old with known cardiovascular pathology (history of cardiac, cerebral, or peripheral vascular pathology) who underwent elective thoracic surgery. Forty-eight patients (27.3%) (95% confidence interval [CI] 20.8%-34.5%) of 177 had diagnostic criteria for MINS. On univariate analysis, an association was found between MINS and smoking (odds ratio [OR] 2.17, 95% CI 1.26-3.76), lobectomy (OR 1.30, 95% CI 1.03-1.66), pneumonectomy (OR 6.72, 95% CI 1.35-33.9), use of vasoactive drugs (OR 1.94, 95% CI 1.03-3.65), and pericardial incision (OR 6.72, 95% CI 1.35-33.9). On multivariate logistic regression analysis, only smoker status and type of surgery were independent risk factors for MINS. No association was found between MINS and 30-day mortality. Based on the findings, the elevated incidence of MINS after thoracic surgery, the independent relationship with the extent of lung resection, and the fact that MINS was not associated with greater mortality suggest that nonischemic causes may contribute to troponin elevation after thoracic surgeries.

Preoperative Detection of Pleural Adhesions Using Ultrasonography for Ipsilateral Secondary Thoracic Surgery Patients

Video-assisted thoracic surgery (VATS) for ipsilateral reoperations is challenging because of the potential for pleural adhesions. Insertion of the initial port can lead to lung injury because of the blinded intrathoracic area. We assessed the usefulness of ultrasonography before VATS to reduce the incidence of lung injury at the time of the initial port insertion during secondary ipsilateral VATS. Thirty-three patients who underwent repeat VATS for ipsilateral pulmonary lesions were included. All patients underwent preoperative ultrasonography to assess the possible presence of pleural adhesions using the lung sliding sign. Seven adhesions were found at the VATS ports. Two of these adhesions were not evaluated as pleural adhesions using ultrasonography; however, they were loose. All initial ports were inserted without lung injury. There were no major complications. Preoperative detection of pleural adhesions using ultrasonography can determine the best initial port for secondary ipsilateral VATS.

The Role of Regional Collaboratives in Quality Improvement: Time to Organize, and How?

Over the last 12 years, surgeon representatives from the 33 participating hospitals of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), along with data specialists, surgical and quality improvement (QI) teams, have met at least 4 times a year to improve health-care quality and outcomes of cardiac and general thoracic surgery patients. The MSTCVS-QC nature of interactive learning has allowed all members to examine current data from each site in an unblinded manner for benchmarking, learn from their findings, institute clinically meaningful changes in survival and health-related quality of life, and carefully follow the effects. These meetings have resulted in agreement on various interventions to improve patient selection, periprocedural strategies, and adherence with evidence-based directed medication regimens, Factors contributing to the quality movement across hospitals include statewide-recognized clinicians who are eager to involve themselves in QI initiatives, dedicated health-care professionals at the hospital level, trusting environments in which failure is only a temporary step on the way toward achieving QI goals, real-time analytics of accurate data, and payers who strongly support QI efforts designed to improve outcomes.

Chest Tube Management Practices by Trauma Surgeons

BackgroundChest tube (CT) placement is among the most common procedures performed by trauma surgeons; evidence guiding CT management is limited and tends toward thoracic surgery patients. The study goal was to identify current CT management practices among trauma providers. Materials and methodsWe designed a Web-based multiple-choice survey to assess CT management practices of trauma providers who were active, senior, or provisional members (n = 1890) of the Eastern Association for the Surgery of Trauma and distributed via e-mail. Descriptive statistics were used. ResultsThe response rate was 39% (n = 734). Ninety-one percent of respondents were attending surgeons, the remainder fellows or residents. Regarding experience, 36% of respondents had five or fewer years of practice, 54% 10 y or fewer, and 79% 20 y or fewer. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with experience of <5 y were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CTs for hemothorax and unstable patients with PTX, and larger tubes for unstable patients with hemothorax. Most respondents (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice. ConclusionsTrauma CT management is variable and nonstandardized, depending mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.

Computer-aided Quantification of Pulmonary Fibrosis in Patients with Lung Cancer: Relationship to Disease-free Survival.

Background Interstitial lung abnormalities (ILAs) are present at CT in about 10% of individuals undergoing lung cancer screening. The relationship between histologic findings of ILAs and their influence on patient prognosis remains unknown. Purpose To evaluate the percentage of ILAs at preoperative CT, as measured by radiologists and a computer-aided detection (CAD) software, as a predictor of disease-free survival in patients with lung cancer. Materials and Methods This retrospective study evaluated 217 consecutive patients who underwent complete resection of lung cancer from April 2010 to December 2015. Two radiologists, blinded to the patients' clinical information, scored percentage fibrosis extent and determined whether ILAs and the usual interstitial pneumonia (UIP) pattern were present. They assessed ILA progression at follow-up CT. Two pathologists determined the presence of an UIP pattern. Percentage fibrosis extent was also measured by using CAD. Binary logistic regression analysis was performed to determine whether the CAD percentage fibrosis extent was associated with ILA at CT. Multivariable Cox regression analysis was used to evaluate the significance of CAD percentage fibrosis extent as a predictor of prognosis. Results The radiologists classified 47 patients with ILAs and 24 patients with a UIP pattern at chest CT. The pathologists detected a UIP pattern in 25 patients. CT abnormalities showed progression over a 2-year period in all patients with histologic evidence of UIP. After adjustment for age, sex, and smoking index, the CAD percentage fibrosis extent was independently associated with ILA (odds ratio: 3.1; 95% confidence interval [CI]: 2.1, 4.7; P < .001). After adjustment for age, forced expiratory volume in 1 second (percentage predicted) radiologist-assessed percentage fibrosis extent, and pathologic stage, CAD percentage fibrosis extent was independently associated with worse disease-free survival (hazard ratio: 1.3; 95% CI: 1.1, 1.6; P < .001). Conclusion Greater computer-aided detection percentage fibrosis extent at preoperative CT independently predicted worse disease-free survival in patients with lung cancer. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Goo in this issue.

Obstructive sleep apnea and perioperative delirium among thoracic surgery intensive care unit patients: perspective on the STOP-BANG questionnaire and postoperative outcomes

According to the Diagnostic and Statistical Manual of Mental Disease (DSM-5), delirium is an acute fluctuating disturbance in attention and awareness. Due to physiologic perturbations, delirium results in cerebral dysfunction and cognitive impairment (1). Among hospitalized patients delirium is associated with increased morbidity, length of stay (LOS), costs and mortality (2). Moreover, there is evidence that patients who develop delirium experience an accelerated degree of long-term cognitive decline compared to those that do not experience delirium while hospitalized (3). In their paper, “Preoperative STOP-BANG Scores and Postoperative Delirium and Coma in Thoracic Surgery Patients,” Wang and colleagues sought to assess the relationships between obstructive sleep apnea (OSA), delirium and postoperative outcomes among thoracic surgery intensive care unit (ICU) patients.

Efficacy of an Ultrasound-Guided Erector Spinae Plane Block for Postoperative Analgesia Management After Video-Assisted Thoracic Surgery: A Prospective Randomized Study

Investigate whether an ultrasound-guided erector spinae plane block (ESPB) can be used to manage postoperative pain in video-assisted thoracic surgery (VATS) patients. Prospective, randomized study. Single institution, academic university hospital. Adult patients who underwent VATS under general anesthesia between September 2018 and March 2019. This study was an interventional study. A total of 60 patients were randomly assigned into 2 groups (n = 30 per group): an ESPB group and a control group. In the ESPB group, a single-shot ultrasound-guided ESPB was administered preoperatively. The control group received no such intervention. All of the patients received intravenous patient-controlled postoperative analgesia, and they were assessed using visual analogue scale (VAS) scores, opioid consumption, and adverse events. There were no statistically significant intergroup differences with respect to the age, sex, weight, American Society of Anesthesiologists status, anesthesia duration, and surgery length (p > 0.05 for each). The opioid consumption at 1, 2, 4, 8, 16, and 24 hours and the active and passive VAS scores at 0, 2, 4, 8, 16, and 24 hours were statistically lower in the ESPB group at all of the time periods when compared with the control group (p < 0.05). In the control group, the nausea and itching rates were higher, but there were no intergroup differences in terms of other adverse effects. A preemptive single-shot ESPB may provide effective analgesia management after VATS.

Improving Self-Reported Preoperative Anxiety Through a Preoperative Education Program: A Quality Improvement Project

Preoperative education is an important component of preparing patients for surgery. Preoperative anxiety is one of the most important problems for patients, because it causes emotional and psychiatric problems as well as physical problems. Anxiety has been associated with several pathophysiological responses such as hypertension and dysrhythmias, which can increase perioperative morbidity. Estimates suggest that between 11% and 80% of adult presurgical patients experience heightened levels of anxiety. The purpose of this pilot project was to develop a preoperative education program for thoracic surgery patients and to assess the effectiveness of the program in decreasing patient's self-reported anxiety levels using the validated Patient-Reported Outcomes Measurement Information System (PROMIS) tool. This quality improvement project used a pre- and posttest improvement design to evaluate patient's self-reported anxiety levels at three different timepoints during the preoperative and postoperative period. A total of 15 patients from a thoracic surgery practice participated in the study. The study showed no statistically significant change in patients' self-reported anxiety levels after completion of the preoperative education program (p = .538). Patients reported improvements in parameters such as expectations, pain, and preparedness. Although some studies have found that preoperative patient education decreases anxiety, this study supports others that indicate that anxiety is not affected by or associated with educational preparation prior to thoracic surgery. Though no statistical improvement in anxiety levels was demonstrated in this study, a majority of patients reported improvements in parameters such as expectations, pain, and preparedness. As patient education is largely provided by the nursing profession, this article will help the profession to better understand what is important for patients to know in the preoperative setting. Setting patient expectations has a great impact on the patient's recovery and satisfaction with their surgical experience. As this is a pilot study, the goal is for continued research in the area of decreasing preoperative anxiety and preparing patients for surgery.

Surgical site infection incidence and risk factors in thoracic surgical procedures: A 12-year prospective cohort study.

Surgical site infections (SSI) continue to be a major problem for thoracic surgery patients. We aimed to determine incidence rate (IR) and risk factors for SSI in patients with thoracic surgical procedures. During 12 years of hospital surveillance of patients with thoracic surgical procedures, we prospectively identified SSI. Patients with SSI were compared with patients without SSI. We operated 3,370 patients and 205 (6.1%) developed SSI postoperatively. We detected 190 SSI among open thoracic surgical procedures (IR 7.1%) and 15 SSI after video-assisted thoracic surgery (IR 2.1%). Five independent risk factors for SSI were identified: wound contamination (p = 0.013; relative risk (RR) 2.496; 95%, confidence interval (CI): 1.208-5.156), American Society of Anesthesiologist (ASA) score (p = 0.012; RR: 1.795; 95% CI: 1.136-2.834), duration of drainage (p < 0.001; RR: 1.117; 95% CI: 1.085-1.150), age (p = 0.036; RR: 1.018; 95% CI: 1.001-1.035) and duration of operation (p < 0.001; RR:1.005; 95% CI:1.002-1.008). The results are valuable in documenting risk factors for SSI in patients undergoing thoracic surgery. The knowledge and prevention of controllable risk factors is necessary in order to reduce the incidence of SSI.

The outcome of thoracic surgery in patients with mental disorder: A case series

The outcome of thoracic surgery in patients with mental disorder: A case series

Качество медицинской помощи больным торакального профиля с позиции сестринского процесса

Качество медицинской помощи больным торакального профиля с позиции сестринского процесса

Big data, big contributions: outcomes research in thoracic surgery.

In recent years, analysis of registry data has defined clinically significant practice patterns and treatment strategies that optimize cancer care for thoracic surgery patients. These higher-order outcome studies rely on large patient cohorts that minimize the risk of selection bias and allow for a powered analysis that is not achievable with single- or multi-institutional data. This review uses recent study examples to highlight important contributions to our knowledge of thoracic surgery and describes how outcomes research using large data can address high impact clinical questions.

ICD-10-CM/PCS: potential methodologic strengths and challenges for thoracic surgery researchers and reviewers.

The recent implementation of the International Classification of Diseases, 10th Revision, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) provides a robust classification of diagnoses and procedures for hospital systems. As researchers begin using ICD-10-CM/PCS for outcomes research from administrative datasets, it is important to understand ICD-10-CM/PCS, as well as the strengths and challenges of these new classifications. In this review, we describe the development of ICD-10-CM/PCS and summarize how it applies specifically to thoracic surgery patients undergoing pulmonary lobectomy, sublobar resection (segmentectomy or wedge resection) and esophagectomy. This myriad of ICD-10-CM/PCS codes presents challenges and questions for thoracic surgery researchers and medical journal reviewers and editors when evaluating thoracic surgical outcomes research utilizing ICD-10-CM/PCS. Additional work is needed to develop consensus guidelines and uniformity for accurate and coherent research methods to utilize ICD-10-CM/PCS in future outcomes research efforts.

Application of Unit-Level Cost Transparency, Education, Enhanced Audit, and Feedback of Anonymized Peer Ranking to Promote Judicious Use of 25% Albumin in Critical Care Units.

Objective: Hyperoncotic 25% albumin is widely used for fluid resuscitation in intensive care units. However, this practice remains controversial. By 2012 in our intensive care unit, annual 25% albumin expenditures had steadily increased to exceed $1 million. This prompted efforts to promote more judicious use. Design: Prospective time series cohort analysis using statistical process control charts. Setting: Seventy-six-bed quaternary level cardiovascular surgical intensive care unit (CVICU), organized into 6 adjacent units. Patients: Adult cardiac, thoracic, and vascular surgery patients admitted postoperatively to the CVICU during the study period. Interventions: Over 12 months starting March 2013, we sequentially implemented unit-level 25% albumin cost transparency, provider education, and individualized audit and feedback of anonymized peer ranking of albumin prescriptions. Measurements and Main Results: C control charts were used for analysis of monthly unit-level direct albumin costs for 20 months. Balance measures including red cell transfusions, number of diagnoses of pleural effusions, and length of stay were also tracked. Monthly average albumin expenditures had decreased 61% by December 2014, and there was no evidence of adverse changes in any of the balance measures. These reductions have been sustained. Conclusion: Sequential implementation of multimodal strategies can alter clinician practices to achieve substantial unit-level reduction in 25% albumin utilization without harm to patients.

Extravascular lung water monitoring for thoracic and lung transplant surgeries

Excessive accumulation of extravascular lung water (EVLW) resulting in pulmonary edema is the most feared complication following thoracic surgery and lung transplant. ICUs have long relied on chest radiography to monitor pulmonary status postoperatively but the increasing recognition of the limitations of bedside plain films has fueled development of newer technologies, which offer earlier detection, quantitative assessments, and can aide in preoperative screening of surgical candidates. In this review, we focus on the emergence of transpulmonary thermodilution (TPTD) and lung ultrasound with a focus on the clinical integration of these modalities into current intraoperative and critical care practices. Recent studies demonstrate transpulmonary thermodilution and lung ultrasound provide greater sensitivity and earlier detection of lung water accumulation and are useful to guide clinical management. Assessments from these techniques have predictive value of postoperative outcome. Further, EVLW assessment shows promise as a preoperative screening tool in lung transplant patients. Monitoring EVLW in the perioperative period offers clinicians a powerful tool to guide fluid therapy and manage pulmonary edema. Both TPTD and lung ultrasound have unique attributes in the care of thoracic surgery and lung transplant patients.

A Prospective Survey Comparing Patients’ Experience of a Nurse-Led Clinic and Consultant-Led Clinic for Surveillance of Patients with Dilatation of the Intrathoracic Aorta

Background: Increasing workload in consultant-led clinics often means patients to wait a long time for clinic appointments. To address this, there is an increasing trend in developing nurse-led clinics across many specialities in the National Health Service. This study aims to assess whether the implementation of a nurse-led clinic in thoracic aortic surgery will optimise the utilisation of health care services and improve overall patient satisfaction. Methods: 80 follow-up patients were asked to complete a questionnaire following their appointment in an aortic clinic, which was led either by a consultant (n = 40) or an aortic specialist nurse (n = 40). All patients seen by a nurse in the clinic were assessed by a consultant surgeon prior to the clinic for suitability. No new patients were seen by a nurse. Any patient with an aortic dimension of 5 cm or greater was seen by the consultant. If there were any complicated clinical features, the patient was seen in the consultant-led clinic. Patients were asked questions about their time spent with the respective health care professionals across 12 categories (punctuality, preparedness, understanding of concerns, clarity of speech, listening, respect, explaining, letting you talk, putting you at ease, emotional support, advice and advice for next follow-up). Patients rated each category using an ordinal scale from 0 - 10. Results: Patient scores were greater in nurse-led clinics compared to consultant-led clinics across a number of categories although only punctuality reached significance (mean 9.2 vs. 6.8, p 0.05). Conclusion: Patients were highly satisfied with the nurse-led clinic across all categories, with greater satisfaction for punctuality. These findings suggest that a nurse-led clinic can be implemented for the management of carefully selected thoracic aortic surgery patient without reduction in patient satisfaction.

An experimental study to check immediate effect of stacked breathing exercise on peak expiratory flow rate in cardiac surgery patient-pilot study

Aims and Objectives: To evaluate the immediate effect of Stacked Breathing Exercise (SBE) on Peak Expiratory Flow (PEFR) in cardiac surgery patient. Methodology: After obtaining an ethical committee clearance, a pilot study is carried out on 11 subjects with age 40- 70yrs planned for cardiac surgery through the mediastinal approach. After obtaining written consent and screening of patient for the inclusion, Patients were treated with a Stacked Breathing Exercise (SBE) on Post-Operative Day (POD) 1, 2 and 3 twice daily. Pre-exercise and post-exercise values for PEFR was collected in six treatment session as IA, IB, IIA, IIB, IIIA, IIIB (A=Morning session, B=Afternoon session and I, II, III was POD-1, 2 and 3 respectively). Result: Total of 11 patients followed by cardiac surgery are analyzed for outcome PEFR. Data was analyzed in term of the mean difference. There is a statistically significant change seen in PEFR value comparing IA vs. IIIA, IB vs. IIIB and IA vs. IIIB (mean difference -86.364, -73.636 and -106.36). There is net 29.77% improvement in PEFR value seen at the end of the sixth (IIB) treatment session over pre-exercise value at IA. Discussion: Statistically significant improvement seen in PEFR value when comparing pre-exercise value to postexercise with every session immediately after the intervention. Our result is best supported with research article carried out by, Luciana Chiavegato. He said, Breath Stacking as an intervention in non-cardiac thoracic surgery patients able to show significant improvement in the Peak Expiratory Flow (PEF). We conducted this study to have to check on, whether it is also effective in cardiac surgery patients? In our study, we found 27% gain over before exercise values of PEFR (in l/ min) after stacked breathing exercise in cardiac surgery patients. Conclusion: It is concluded that stacked breathing exercise is significantly effective in improving PEFR. Hence can be an effective tool to help in improving lung function.