mise à jour du
1 juillet 2004
Surgical Forum
1971; 22; 196-198
 The yawn maneuver :
prevention and treatment of postoperative
pulmonary complications
RH Bartlett, AB Gazzaniga, T Gerathy
Department of surgery, University of california, Irvine


Diminished lung volume and hypoxemia following laparotomy or thoracotomy, progressing to clinically significant pulmonary complications, are not unusual. A major cause of progressive alveolar collapse is the abnormal pattern of ventilation characteristic of the postoperative period: shallow tidal breathing without spontaneous deep breaths. A respiratory maneuver should include high alveolar inflating pressure (preferably negative intrathoracic pressure) applied for a long time, achieving the maximum inspired volume to prevent or treat atelectasis. Voluntary sustained maximal inspiration (SMS) with the glottis open (a yawn) is the ideal maneuver (1), but is difficult to induce in patients. A device which assures these conditions was used to quantitate the physiologic effects of the maneuver. SMI reverses the alterations in postoperative pulmonary function (2). The purpose of this study was to determine if regular voluntary yawning using the device could decrease the incidence of pulmonary complications.
The incentive spirometer assures reproducible SMI to total lung volume, rewards the patient with a light signal, and records each SMI maneuver. One hundred adults consecutively undergoing elective laparotomy were randomly placed in a treated or control group with the exception that those with chronic pulmonary disease were selected for the treated group. Hospital staff carried out deep breathing, coughing, and early ambulation in all patients, and suctioning, drug administration, blood gases and assisted ventilation as indicated. Temperature, vital signs, sputum production, physical findings, and vital capacity were recorded daily by the investigators. Chest x-rays were done pre-operatively and on the second and fourth postoperative days. Patients in the treated group were instructed preoperatively in use of the spirometer and encouraged to yawn at least 10 >< an hour after operation. There was no difference between the treated versus control groups in average age (50 vs. 48), pre-op vital capacity (2718 vs. 2637), days of nasogastric tube (1.7 vs. 2.3), anesthesia time or agent, type of operation or incision.
X-ray abnormalities developed postoperatively in 48% of control and 30% of treated patients. Pulmonary complications were defined as fever over 100°, sputum production, abnormal physical findings, and abnormal chest x-ray. Pulmonary complications developed in 15 control patients (30%) and 5 treated patients (10%). Among the 15 control patients with complications, 11 required antibiotics, 10 suctioning, and one assisted ventilation. Seven patients were hospitalized for more than 10 days after operation. Of the 5 treated patients with pulmonary complications, 1 required antibiotics, 1 suctioning, and none assisted ventilation. One patient was hospitalized for more than 10 days after surgery. One of these 5 developed atelectasis secondary to pleural effusion following splenectomy, 2 developed lobar atelectasis on the second day, re-expanded by the fifth day, and 2 were elderly females who had difficulty using the device, averaging 35 yawns per day. [Average for the group, 140 (15-650)]. The SMI maneuver has also been used successfully to treat 10 patients with established atelectasis unresponsive to conventional management.
Although many maneuvers and devices have been proposed to prelent pulmonary complications, only deep breathing has been consistently effective (3). The incentive spirometer assures reproducible sustained maximal inspiration, is well accepted by patients, and records the frequency of the prescribed breathing exercises. Altering the pattern of ventilation to include regular SMI (yawning) with an incentive spirometer reduced the incidence of postoperative pulmonary complications in this study from 30% to 10%.
1. Ward RS, Danziger F, Bonica jj, et al: An evaluation of postoperative respiratory maneuvers. Surg Gynecol Obstet 123:51, 1966
2. Bartlett RH, Krop RH, Hanson EL, et al: Physiology of yawning and its application to postoperative care. Surg Forum 21:222, 1970
3. Bartlett RH: Post-Traumatic Pulmonary Insufficiency. Surgery Annual. New York, Appleton Century Crofts, 1971
4. Cahill CA Yawn maneuver to prevent atelectasis AORN 1978; 27; 5; 1000-1004
5. Crosby L; Parsons LC Clinical neurologic assessment tool: development and testing of an instrument to index neurologic status.Heart Lung 1988; 18; 2; 121-9
 Neurological assessment of coma (pdf)
David E Bateman
J Neurol Neurosurg Psychiatry
2001; 71(suppl I); i13Ði17