mise à jour du
16 septembre 2004
1978; 27; 5; 1000-1004
Yawn maneuver to prevent atelectasis 
Cheryl A Cahill
Department of Biological Dysfunction of the School of Nursing
University of California, San Francisco


Respiratory complications, atelectasis in particular, account for the majority of postoperative complications experienced by patients. They result in prolonged hospitalization, increased economie impact, and, in some cases, loss of life. The most disturbing aspect of this problem is that it is predictable and preventable.
It is the duty of the nurse to prevent atelectasis. Traditionally, the intervention has been to have the patient turn from side to side, take deep breaths, and cough. The effectiveness of the deep breath for all patients is questionable. For patients who have had abdominal surgery, the pain resulting from increased tension on the incision may prevent effective deep breathing. The yawn may be more efficient and effective because it is a deep inspiration held for a prolonged period of time. It can be elicited by a simple command and is difficult to stop once it bas been initiated.
Atelectasis. The etiology of atelectasis is well known. If the patient is given a general anesthesia and placed on a respirator during the surgical procedure, some degree of atelectasis is present when the patient is removed from the operating table. Atelectasis, the collapse of alveoli, results from alveolar hypoventilation. The normal respiratory pattern of spontaneously breathing adults includes periodic sighs or deep breaths. When the person is anesthetized, placed in one position, and ventilated at a constant tidal volume, the periodic sighs are eliminated and alveoli collapse. The problem is further complicated by the fact that the sigh reflex is absent in spontaneously breathing postoperative patients. The result is increased collapse of alveoli, arteriovenous shunting of blood in the pulmonary circulation, and systemic hypoxia. Periodic hyperinflation of the lungs is sufficient to reinflate collapsed alveoli.
Development of hypoxia. The primary problem to be dealt with is the hypoxia that develops in clinically significant atelectasis. The respiratory pattern exhibited in the postoperative period is characterized by increased respiratory rate, decreased tidal volume, and loss of the sigh reflex. The result is adequate excretion of CO2 by the lungs, maintenance of arterial pH at normal levels, and decreased arterial O2 levels.
As alveoli collapse, there is less respiratory membrane available for the exchange of gases. The initial result is a buildup of carbon dioxide in the bloodstream. An increase in arterial carbon dioxide stimulates the respiratory center located in the brain to increase the respiratory rate. As the respiratory rate increases, excess carbon dioxide is blown off, but oxygen levels remain low. It takes longer for oxygen to diffuse into the bloodstream and attach to the hemoglobin than it does for carbon dioxide to diffuse out of solution into the alveoli. If the postoperative patient's arterial blood gas values were determined, they would indicate normal arterial carbon dioxide, normal arterial pH, and a lowered arterial oxygen level. This hypoxia is the problem that nurses face. Hypoxia feeds into the fatigue experienced by surgical patients. It contributes to the confusion experienced by elderly postoperative patients and has some effect on the irritability and discomfort experienced by postoperative patients. The classic signs and symptoms of hypoxia, such as cyanosis, tachypnea, shallow breathing, altered breath sounds, hypertension, and tachycardia, may not be readily evident in the postoperative patient and to wait for them to develop is unnecessary. All postoperative patients experience some degree of atelectasis and therefore hypoxia. The nurse should treat it to prevent further complications.
Treating and preventing atelectasis. Some interventions traditionally used are intermittent positive pressure breathing, blow bottles, and incentive respirometers. Balagot and Bandelin pointed out that "the occasional or even frequent augmentation of inspiration (sigh) may be more helpful in preventing atelectasis than all the paraphernalia and accessories which make inhalation therapy impressive and expensive."
In practice, it is sometimes difficult to attain the cooperation of patients when encouraging them to deep breathe and cough. This is particularly true of patients who have had thoracic or abdominal surgery. In these cases, incisional pain may decrease the respiratory effort the patient can exert. Also, tthese patients require pain medications that may suppress the respiratory center and cough reflex. It is difficul to be certain that when a patient is asked to take a deep breath, they are indeed increasing their inspiratory volume sufficiently to reexpand collapsed alveoli. For a deep breath to ventilatte the lungs sufficiently to reinflate collapsed alveoli, it must be at least twice age tidal volume, include high alveolar inflating pressure, be applied for a prolonged period of time, and achieve maximum inspiratory volume. The particular respiratory maneuver that does all these things is a yawn.
The yawn maneuver. The yawn maneuver has advantages over deep breathing. In a study conducted by Ward and others, it was concluded that a yawn, which was defined as a deep breath held for three seconds, significantly increased arterial oxygen levels over series of deep breaths and a single deep breath. In another study where the subjects were asked to yawn, the increased inspiratory volume wa maintained a mean time of 5.21 seconds. All patients know what it feels like to yawn, so when they are asked to yawn, they know when they have succeeded. This yawn maneuver itself possesses certain features that make it useful in clinical situations. First, the yawn is a spontaneous deep inspiration difficult to stop once it bas started. So, the patient who has been reluctant to takea deep breath because of incisional pain will find it difficult to stifle a yawn once it is initiated. Second, the initiation of a yawn is relatively easy. Since the yawn can be elicited by suggestion, the nurse need only ask the patient to yawn, discuss yawning, or yawn herself to obtain the desired patient response. In one study, the regular use of the yawn maneuver reduced postoperative pulmonary complications by 20%.
Summary. Postoperative respiratory complications are frequent. The main complication is atelectasis, with hypoxia as a primary problem. Hypoxia is a result of venous or unoxygenated blood flowing past collapsed alveoli and mixing with oxygenated blood. Alveolar collapse is the result of the absence of the sigh reflex in the postoperative respiratory pattern of patients. Alveolar collapse can be reversed by increasing the depth of inspiration to three times the average tidal volume and prolonging the inspiratory phase of the respiratory excursion. Another name for this type of respiratory movement is a yawn. The yawn is easily elicited in patients by suggestion or contagion.
It is within the scope of nursing care to prevent atelectasis from developing in patients. The usual treatment includes turning, coughing, and deep breathing by the patient at least every two hours. The yawn maneuver should be substituted for deep breathing because it has been shown to be more effective in reinflating collapsed alveoli and, therefore, in treating or preventing hypoxia.
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