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Table of Contents
RESEARCH ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 166-170

Effectiveness of quick relaxation technique on pain associated with chest tube removal among postoperative coronary artery bypass grafting patients in a Tertiary Care Hospital, Delhi


Assistant Professor, College of Nursing, Army Hospital (R and R), New Delhi, India

Date of Submission06-Jul-2019
Date of Decision17-Aug-2020
Date of Acceptance01-Sep-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Miss. Jilmy Anu Jose
Assistant Professor, College of Nursing, Army Hospital (R and R), New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCN.IJCN_134_20

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  Abstract 

The current burden of coronary artery disease in India is >32 million. Chest tube removal (CTR) is a common procedure in critical care units and post coronary care units and is associated with moderate-to-severe pain. The pain management protocols remain unsatisfactory for most patients and researchers recommend the development and introduction of new protocols. Even with pharmacological management, most patients remember chest removal as a painful and discontented moment. Advanced practice nurses remove chest tubes most often. The aim of the present study was to assess the effectiveness of quick relaxation technique (QRT) on CTR for reducing the pain levels experienced by patients and also adopting it as a routine practice in cardiac surgical units. An experimental design was used. Sixty patients who were posted for coronary artery bypass grafting (CABG) were selected using purposive consecutive sampling method and randomly allotted to the experimental and control group. QRT was implemented to experimental group patients along with the regular protocol before drain removal. Control group patients underwent the regular protocol followed in surgical intensive care unit. The structured assessment tool was developed and used for data collection, which consisted of demographic data, information related to chest tube and numerical rating scale for pain assessment. Out of the 60 patients majority were in the age group of 60–70 years and majority were male in the control and experimental groups. Control group had mean post-procedure pain score of 5.1 ± 1.14, whereas the experimental group had mean pain score of 3.7 ± 1.05. QRT was highly effective in reducing the pain level on chest tube drain removal of post-CABG patients (Unpaired t-test value of 5.6394 with df 58, P < 0.0001). The study will be useful in identifying QRT as an important intervention in reducing pain associated with CTR. QRT can be used as a routine practice before CTR in the cardiac surgical unit. Hospitals and nursing institutes should prepare guidelines for QRT along with routine pharmacological management during CTR for better patient satisfaction.

Keywords: Coronary artery bypass grafting, chest tube removal, pain, quick relaxation technique


How to cite this article:
Jose JA. Effectiveness of quick relaxation technique on pain associated with chest tube removal among postoperative coronary artery bypass grafting patients in a Tertiary Care Hospital, Delhi. Indian J Cont Nsg Edn 2020;21:166-70

How to cite this URL:
Jose JA. Effectiveness of quick relaxation technique on pain associated with chest tube removal among postoperative coronary artery bypass grafting patients in a Tertiary Care Hospital, Delhi. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Feb 28];21:166-70. Available from: https://www.ijcne.org/text.asp?2020/21/2/166/309850


  Introduction Top


The current burden of coronary artery disease in India is >32 million.[1] Cardiac surgery may cause peri-operative stress and severe pain postoperatively.[2] Inadequate pain management during the post-operative period after cardiac surgery results in high morbidity, longer duration of hospital stay and poor health outcomes for patients.

Recovery and prognosis of cardiac surgery patients depend on respiratory exercises and early ambulation. Deep breathing, coughing exercises and ambulation of cardiac surgery patients can be attained with effective teaching, support and pain management.[3],[4],[5] In cardiac surgery patients, the pain is mostly caused from sternal splitting and drainage catheter insertion which are at maximal pain locations.[6],[7] Chest drains are inserted to allow the removal of air, blood or fluids from the thoracic cavity and prevent them from re-entering the cavity.[8]

All cardiac units have their own accepted protocols for drain removal under the decision of treating physicians. Chest tube removal (CTR) is a common procedure in critical care units and post coronary care units. Movement of chest tubes while coughing, sitting up, deep breathing and ambulation may be the cause of pain for the post-cardiac surgery patients. After the removal of chest tubes, the patients' pain decreases significantly during movements and ambulation.[9]

Background

It is known that CTR is associated with moderate-to-severe pain. Experts from the field of cardiac surgery have encouraged the development of protocols for the pharmacologic management of pain associated with CTR.[10] The protocols mostly remain unsatisfactory and most patients remember CTR as a painful and dissatisfied experience.

Friesner et al. conducted a study to compare pain management strategies during CTR: Relaxation exercise with opioid and opioid alone. The study found that there was a significant difference in pain ratings immediately after CTR and 15 min after CTR for the group receiving relaxation exercise as an adjunct to opioid analgesic.[11] A randomised, double-blind, placebo-controlled study using valdecoxib topical application versus liquid paraffin (placebo) during CTR revealed that the use of topical valdecoxib as analgesic for CTR in cardiac patients was a safe and effective method.[12] In another study, cold application was shown to reduce pain significantly during CTR compared to the control group. The study also revealed that there was no significant effect of age, gender, indication and duration of chest tube insertion in days on the pain during CTR.[13]

Nurses with specific training in cardiovascular and thoracic surgery nursing or advanced practice registered nurses who have been privileged for CTR performed the CTR in this setting. The aim of the present study was to assess the effectiveness of quick relaxation technique (QRT) on CTR for reducing the pain levels experienced by patients and adopting it as a routine practice in cardiac surgical units.

Objectives of the study

  1. To assess the level of pain before and after CTR in control and experimental groups
  2. To compare the pain reduction between the experimental group and control group after CTR at post assessment.



  Methodology Top


An experimental research design was used for the study. The cardiothoracic surgical intensive care unit of a tertiary hospital was selected as the study setting. The study population consisted of hospitalised patients undergoing coronary artery bypass grafting (CABG) surgery. The sample size was calculated based on previous studies[12],[14] with a 0.05 level of significance and 80% power. The sample size calculated was 23 patients in each group and the researcher included 30 patients in each group considering attrition and availability of sample.

A total of 60 patients who underwent elective CABG were selected for the study by consecutive sampling method. Patients undergoing other cardiac procedures associated with CABG, patients with life-threatening co-morbidities, emergency CABG and redo CABG were excluded from the study. Patients were randomly allotted to both experimental and control groups by the lottery method. The patients with two chest tubes one below the xiphisternal area and other along intercostal space of the left mid-clavicular area to drain left pleural space were included. Both the chest tubes were connected with Y connector to single water seal drainage container with negative pressure.

Trained nurses in the cardiac surgical unit did CTR and the data collection. Patients were made to sit on a chair or bedside before CTR. The pain was assessed using numerical pain rating scale (NPRS). Patients in the experimental group did QRT before CTR with the help of two nursing officers who learned and practiced QRT for research purposes. The intervention took 5–10 min. QRT brings relaxation through deep awareness and regulation of the breath.[14] The patients were instructed to close eyes and breathe in and out and simultaneously observe the movements of abdominal muscle moving up and down. The same exercises were repeated for 7 cycles. The patients were instructed to inhale deeply and slowly to energise the whole body and feel the lightness and also chant A sound (A-Kara) during exhalation. While exhaling they were instructed to completely relax all muscles and relax completely. They were encouraged to open the eyes with few blinks once completely relaxed. All the patients in both groups were educated about deep breathing exercises during the pre-operative time and were practicing postoperatively, but the experimental group patients were instructed to do QRT under guidance of nursing officers.

Ethical clearance for conducting the study was taken from the Institutional Ethical Committee. Before data collection, permission was obtained from the head of the institution, heads of department, treating physicians and the nursing officers involved. Informed consent was taken from patients. The privacy of subjects was maintained throughout the study and thereafter. Routine nursing care was provided to the subjects during the study irrespective of the experimental and control group. The experimental group received QRT before CTR in addition to the routine analgesic dose administered. Both the groups received the routine prescribed analgesic dose of Injection Paracetamol 1-g 8 hourly and Injection Tramadol 50 mg, si opus sit (SOS) as per doctors' review and order.

Numeric Pain Rating Scale (NPRS) was used to assess the pain 15 min before the procedure and 15 min after the procedure. NPRS is a unidimensional measure of pain intensity in adults, which is a segmented numeric version of the visual analogue scale. In NPRS, the patient selects a number from 0 to 10 which defines the intensity of their pain. The format used was a horizontal line marked from 0 to 10 on white paper pasted on cardboard. This numeric scale with 11-points represents “0” as no pain and 10 as extreme pain.[15]


  Results Top


Out of the 60 patients majority were in the age group of 60–70 years in the experimental group (43%) and in the control group (40%). In the control group, 25 (63.33%) were male and 05 (16.66%) were female. In the experimental group, 24 (80%) were male and 06 (20%) were female. Eighty-eight percent of the sample were married and 12% widow or widower. Thirty-eight percent (23) of the patients were practicing breathing asana of yoga but none were trained in yoga. Sixty-two percent (37) of the sample were not practicing yoga during daily life. All the patients were practicing deep breathing exercises during the pre-operative period.

Two patients in the control group and one patient in the experimental group underwent CABG of one blockage. Thirty-eight out of 60 patients underwent CABG with 3 or more blockage. Three (10%) underwent CABG for 4 blockage in the control group, whereas 10 (33.33%) in the experimental group underwent the same surgery. CABG for 5 coronary artery blockage correction was done totally for 15 (25%) patients [Table 1].
Table 1: Distribution of sample as per coronary artery bypass grafting of number of blockage

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Pain score was assessed 15 min prior to CTR in both experimental and control groups. Majority, 73.3% in the control and 70% in the experimental group, perceived severe pain at pre-procedure assessment. After 15 min of CTR, none of the patients had severe pain in both groups. In the post-assessment majority, (24, 80%) patients reported moderate pain or mild pain (6, 20%) in the control group. In the experimental group, majority (26, 86.6%) reported mild pain and the rest (4, 10.4%) reported moderate pain in the post-assessment [Figure 1].
Figure 1: Comparison of pain score in control and experimental group before and after procedure of chest tube removal

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The mean pre-procedure pain score was 7.6 ± 1.15 and 7.63 ± 1.29 in the control and experimental group, respectively, and was not statistically different [Table 2].
Table 2: Pre-procedure pain comparison among experimental and control group

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Analysis of pain score after removal of chest tube drain showed that the mean pain score was 5.1 ± 1.14 in the control group and 3.7 ± 1.05 in the experimental group which was significantly different (P < 0.0001) [Table 3]. There was a pain score reduction in both groups, but the significant difference in post score denotes that QRT was highly effective in reducing the pain level of patients during the removal of chest tube drain.
Table 3: Post-procedure pain comparison among experimental and control group

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Association of pain at post removal of chest tube with demographic characteristics and the type of surgery was also done for both experimental and control group patients. No significant association was found between age, gender and the type of surgery with the pain score of the patients' post removal of the chest tube.


  Discussion Top


In the present study, numerical pain scale was used to assess the pain level before and after CTR. NPRS was selected over visual analog scale as it takes few seconds to score, and this scoring method has minimal language or cultural differences. It could be scored by the verbal response of the patient by just pointing to show the number on the scale and therefore did not interfere with the ability of subjective expression of pain. In Refai et al.'s study on the impact of CTR on pain, similar numerical pain scale ranging from no pain (0) to excruciating pain (10) was used.[16]

Pain assessment before, during and after CTR was explained in most of the literature studied. CTR procedure generally takes a few seconds and the patient is asked to hold the breath during the procedure. Hence, subjective assessment of pain during the procedure of CTR using a numerical pain scale is difficult. In the present study, the researcher assessed the pain before and after the CTR.

The intervention adopted for the study is QRT which has shown much benefits above pharmacological management.[14],[17],[18] QRT helps the patient to relieve the stress and tension and relax completely. The study conducted by Friesner et al. on the comparison of two pain management strategies also supports the slow deep breathing relaxation exercise as effective in reducing pain. QRT can be used as an adjunct to the use of opioids during CTR among CABG patients to reduce the pain level.[11] The present study also reveals that 80% of CABG patients expressed moderate pain after CTR in the control group. Whereas 86.6% reported only mild pain and 10.4% shown moderate pain with QRT in the experimental group during CTR. Pain relief is the most important aspect of care and QRT helps to reduce the pain among CABG patients during CTR. This technique will also help us to have non-pharmacological management as an adjunct to pharmacological management of pain.

The present study shows severe pain in both the control and experimental group 15 min before the CTR. This is the pain expressed by the study subjects through NPRS when they were on regular pain medication. The severe pain score before procedure may be due to the preparation and positioning of patients for CTR and anxiety of patients before procedure. In a study on pain levels experienced with activities after CABG from day 1 to 6 and the pains reports before and after CTR and extubation, the pain scores were found to be higher on earlier postoperative days with high pain during coughing, moving or turning in bed and getting up. After chest tubes were discontinued, patients had lower pain levels at rest.[19]

The significant difference between the pain level of control and experimental group 15 min after the CTR validates the effectiveness of QRT and also the regular pharmacological measures. However, the significant difference in post-assessment scores between the control and experimental groups denotes the effectiveness of QRT as adjuvant in improving pain reduction. A study on the effect of QRT on pain associated with CTR by Houston and Jesurum states that conventional methods used to prepare patients for CTR are not effective in reducing pain.[14] The QRT was used on 24 primary aorta-coronary bypass surgical patients. Visual analog scale was used to rate pain immediately after CTR and 30 min later. Results indicated that men more than or equal to 70 years of age who received QRT scored half the pain in comparison with others who did not receive QRT. The study did not find any significant difference in pain scores among patients <70 years of age. On contrary to these findings, in the present study, a significant difference in pain score between patients who received QRT along with routine analgesics and the patients who did not receive QRT was seen irrespective of the age of patients. The results from this study also showed that pain post removal of chest tube did not have any significant association with age gender or type of surgery underwent.

The study limitations include the limitation of the numerical pain scale that gives the subjective data of pain and the possible varying of pain score. NPRS measures only the intensity of the pain it does not measure the complex nature of pain. Inadequate subject availability after satisfying inclusion criteria forced the researcher to select all patients as per inclusion criteria who underwent CABG during the data collection phase. However, randomisation was followed. The third limitation was that different cardiac surgeons did the CABG surgery, and different trained nurses did CTR and this could affect the pain experiences of patients.


  Conclusion Top


Studies on nursing interventions will help to improve the nursing techniques and results in better patient care and health outcome. The present study is also aimed to reduce the pain level of patients during CTR. The study results will be useful in identifying QRT as an important intervention in reducing pain associated with CTR. Further studies are recommended in a large scale and with other nonpharmacological pain control measures to reduce pain level during CTR.

QRT can be used as a routine practice before CTR in the cardiac surgical unit. Hospitals and nursing institutes should prepare guidelines for patient teachings on QRT during postoperative phase.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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World Health Organization. Cardiovascular Diseases. 2020. Available from: http://www.who.int/mediacentre/factsheets/fs317/en/. [Last accessed on 2020 Dec 12].  Back to cited text no. 1
    
2.
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Sasseron AB, Figueiredo LC, Trova K, Cardoso AL, Lima NM, Olmos SC, et al. Does the pain disturb the respiratory function after open heart surgery? Rev Bras Cir Cardiovasc 2009;24:490-6.  Back to cited text no. 5
    
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Standring S. Gray's Anatomy E Book: The Anatomical Basis of Clinical Practice. USA: Elsevier; 2015. Available from: https://www.elsevier.com/books/grays-anatomy/standring/978-0-7020-5230-9. [Last accessed on 2020 Dec 12].  Back to cited text no. 8
    
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Kang H, Chung YS, Choe JW, Woo YC, Kim SW, Park SJ, et al. Application of lidocaine jelly on chest tubes to reduce pain caused by drainage catheter after coronary artery bypass surgery. J Korean Med Sci 2014;29:1398-403.  Back to cited text no. 9
    
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Bruce EA, Howard RF, Franck LS. Chest drain removal pain and its management: A literature review. J Clin Nurs 2006;15:145-54.  Back to cited text no. 10
    
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Friesner SA, Curry DM, Moddeman GR. Comparison of two pain management strategies during chest tube removal: Relaxation exercise with opioids and opioids alone. Heart Lung 2006;35:269-76.  Back to cited text no. 11
    
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Ertug N, Ulker S. The effect of cold application on pain due to chest tube removal. J Clin Nurs 2012;21:784-90.  Back to cited text no. 12
    
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Singh M, Gopinath R. Topical analgesia for chest tube removal in cardiac patients. J Cardiothorac Vasc Anesth 2005;19:719-22.  Back to cited text no. 13
    
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Houston S, Jesurum J. The quick relaxation technique: Effect on pain associated with chest tube removal. Appl Nurs Res 1999;12:196-205.  Back to cited text no. 14
    
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Layzell M. Improving the management of postoperative pain. Nurs Times 2005;101:34-6.  Back to cited text no. 15
    
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Refai M, Brunelli A, Salati M, Xiumè F, Pompili C, Sabbatini A. The impact of chest tube removal on pain and pulmonary function after pulmonary resection. Eur J Cardiothorac Surg 2012;41:820-3.  Back to cited text no. 16
    
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Sadeghi MM, Etesampour A, Gharipour M, Shariat Z, Nilforoush P, Saeidi M, et al. Early chest tube removal after coronary artery bypass graft surgery. N Am J Med Sci 2009;1:333-7.  Back to cited text no. 17
    
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