INCENTIVE SPIROMETRY
USE FOLLOWING
ABDOMINAL SURGERY
James Barry, BS
Stacy Marsden, MA
Jill Stewart, MBA
MSN Clinical Nurse Leader Program, College of Nursing
Georgia Regents University
Background
• Abdominal surgery is associated with high risk of post-
operative pulmonary complications (PPC)
• Without a therapeutic respiratory regimen, up to 25% of
abdominal surgery patients develop PPC (Deodhar, 1991)
• Post-operative pulmonary complications include:
• Respiratory failure
• Atelectasis
• Pneumonia
• Bronchospasm
• Tracheobronchitis
• Incentive spirometry (IS) and deep-breathing exercises
(DBE) can reduce the risk for PPC
Purpose
• The literature review was performed to answer the
question, “For post-operative abdominal surgery patients
does the use of an incentive spirometer reduce the risk of
pulmonary complications compared with a regimen of
deep breathing exercises?”
• Determining whether IS or DBE use is more effective
could play a significant role in the reduction of morbidity
and mortality, improving health outcomes, and reducing
health costs following abdominal surgery.
Literature Search Strategy
• Databases searched: CINAHL, Cochrane, Google Scholar,
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•
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Medline, Ovid
Key search terms: deep breathing exercises, incentive
spirometry, pulmonary complications, post abdominal surgery,
Target population: adult patients at risk for pulmonary
complications following abdominal surgery
Inclusion criteria: studies that compare the effectiveness of
DBE versus IS use in the prevention of PPCs in adults
Exclusion criteria: pediatric studies, pre-surgical
interventions, non-abdominal surgery
Articles: 20 articles reviewed, nine articles selected ranging
from 1984-2011 (paucity of studies in the last five years)
Results: Table 1
Intervention
Incentive Spirometry (IS)
Alone
n/N
Percentage
Study
35/231
7/21
5/20
8/20
15%
33%
25%
40%
Sweiger, 1986
8/76
11%
Hall, 2006
Mixed IS and DBEx
28/225
12%
Hall, 2006
No treatment
17/19
9/20
6/20
89%
45%
30%
Celli, 1984
Deep Breathing Exercises
(DBEx) Alone
Hall, 2006
Celli, 1984
O’Conner, 1988
O’Conner, 1988
Sweiger, 1986
Results: Figure 1 - Risk Ratio
Evidence Hierarchy
Level of
Evidence
Type of Study
Author
1a
Systematic Review
Carvahlo, Paisani, & Lunardi (2011)
1b
RCT
Celli, Rodriguez, & Snider (1984)
3b
Case-controlled
Deodhar, Mohite, Shirahatti, & Joshi
(1991)
1b
RCT
Guimaraes, El Dib, Smith & Matos (2009)
1a
RCT
Hall, J. C., Tarala, Tapper & Hall, J.L
(1996)
1a
RCT
O’Connor, Tattersall, & Carter (1988)
1a
RCT
Schweiger, Gamulin, Forster, Meyer,
Gemperle, & Suter (1986)
1a
Systematic Review
Thomas & McIntosh (1994)
Legend: 1a=systematic review of RCTs, 1b=indiv. RCTs, 2a=systematic rev. of cohort
studies, 2b=indiv. Cohort studies & poor RCTS, 3a=systematic rev. of case-control studies,
3b=indiv. case-controlled studies, 4=poor quality case-controlled and cohort studies,
5=expert opinion based on clinical experience
Limitations
• Inconsistencies across studies in the definition of PPCs,
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methodology of data analysis
Effectiveness of IS and DBE depends on patient
selection, treatment dosage, instructions given,
supervision during respiratory training, and patient
adherence
Tidal volumes not measured in all studies
Not all trials are randomized
The short follow-up period for most patients limits analysis
of IS effectiveness
The incidence of PPCs varies dramatically depending on
the type of surgery and patient’s health status
Recommendations for Practice
• Continuation of current practice is recommended based
on analysis of available evidence
• Implementation of either IS use or DBE following
abdominal surgery
• Incentive spirometry
• Hourly during waking hours with 10 maximal breaths per
session
• Deep breathing exercises
• 4 to 5 times daily during waking hours
Barriers to Implementation
Barriers
• Requires education and supervision
• Ineffective unless performed as instructed
• Time and cost involved
• Patient adherence
• Patient health status and level of consciousness (LOC)
Suggestion to overcome barriers
• Nurse and patient education
• Incorporation of IS implementation during hourly rounding
• Supervision for adherence and proper use
• Family member assistance
• Keep IS in patient’s line of sight
Conclusion
• IS and/or DBE are more effective than no respiratory
therapy in the prevention of PPCs
• There is no evidence to support a statistically significant
difference between IS use and DBE for the prevention of
PPCs in post-operative abdominal surgery patients
• Additional research with adequate methodological
designs is needed to clarify the effect and to justify the
use of IS over DBE
References
Carvalho, C., Paisani, D.M., & Lunardi, A.C. (2011). Incentive spirometry in major
surgeries: a systematic review. Brazilian Journal of Physical Therapy, 15,
343-350.
Celli, B.R., Rodriguez, K., & Snider, G.L. (1984). A controlled trial of intermittent
positive pressure breathing incentive spirometry and deep breathing
exercises in preventing pulmonary complications after abdominal
surgery. The American Review of Respiratory Disease, 130, 12-5.
Deodhar, S.D., Mohite, J.D., Shirahatti, R.G., & Joshi, S. (1991). Pulmonary
complications of upper abdominal surgery. J Postgrad Med, 37, 88-92.
Guimaraes, M.M., El Dib, R., Smith, R.F., & Matos, D. (2009). Incentive spirometry
for prevention of postoperative pulmonary complications in upper
abdominal surgery. Cochrane Database System Rev, 3. doi:
10.1002/14651858.CD006058.pub2.
Hall, J.C., Tarala, R.A., Tapper, J., & Hall, J.L. (1996). "Prevention of respiratory
complications after abdominal surgery: A randomised clinical trial." BMJ,
312(7024), 148-152.
References
National Guideline Clearinghouse. (2011). Incentive spirometry: 2011.
Retrieved from http://www.guidelines.gov/content.aspx?id=34793.
O'Connor, M., Tattersall, M.P., & Carter, J.A. (1988). An evaluation of the incentive
spirometer to improve lung function after cholecystectomy.
Anaesthesia, 43(9), 785-7.
Schwieger, I., Gamulin, Z., Forster, A., Meyer, P., Gemperle, M., & Suter, P.M.
(1986). Absence of benefit of incentive spirometry in low-risk patients
undergoing elective cholecystectomy. A controlled randomized
study. Chest, 89(5), 652-6.
Thomas, J. A., & McIntosh, J.M. (1994). 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. Physical
Therapy, 74(1), 3-10.