Running head: THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
1
Does Incentive Spirometer Use offer a Better Choice for Preventing Pulmonary Complications in
Abdominal/Thoracic Surgery Patients Compared to no therapy or Use of other Therapies?
Jean -Baptiste Rangira Kagabo
Ferris State University
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
2
Abstract
In hospitals or at home, patients who underwent surgery use different methods in order to prevent
or treat post-operative pulmonary complications (PPCs) that may arise. The use of incentive
spirometer is one of such therapeutic methods. The purpose of this paper is to review the literature
about the use of incentive spirometer and other preventative and therapeutic methods. A
comparison is made in order to determine if the use of incentive spirometer is the better choice in
preventing or treating PPCs compared to no treatment or other therapy techniques such as deep
breathing exercises (DBE), or physiotherapy. CINAHL, COHRANE, and PubMed were used to
find relevant articles that discuss the use of different methods used to prevent or treat PPCs. The
review of literature showed not difference between IS when compared to other preventative or
therapeutic methods in preventing or treating PPCs. After the review of literature, it is evident that
there is a lack of current research on the benefit of IS or other therapies used in the prevention of
PPCs, therefore highlighting a need for further research in this area.
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
3
Does Incentive Spirometer Use offer a Better Choice for Preventing Pulmonary Complications in
Abdominal/Thoracic Surgery Patients Compared to no therapy or Use of other Therapies?
According to Rupp et al. (2013) post-operative patients who underwent abdominal or
thoracic operation are at higher risk of PPCs compared to other post-operative patients. This
greater risk is a result of physiological changes after surgery. For example, deep breathing is
affected by increased pain, and pressure at the surgical site, generalized weakness of the
abdominal or intercostal muscles due to incisions, and abdominal binder that is often worn by
post-operative patients. If the deep breathing is affected, other system body systems such as
nervous, and circulatory systems can be affected due to insufficient oxygen. With this knowledge
of greater risk, physicians prescribe varying therapeutic to try and prevent PCCs. This paper will
interpret research findings in order to see if incentive spirometer provides a better choice for
preventing PPCs compared to no therapy or other therapeutic techniques.
Clinical Question
According to Overend et al. (2001) the risk rate of PPCs in patients who undergo upper
abdominal surgery is between 17% and 88%. However, Agostini and Singh (2009) indicated
that the risks PPCs after thoracic surgery have been recorded at between 19% and 59%,
compared with only 16% and 17% for upper abdominal surgery and 0% and 5% for lower
abdominal surgery. On the other hand, studies indicated that PPCs after surgery are reported
between 2% and 39% and include atelectasis, pneumonia, and pulmonary failure (Fisher,
Majumdar, & McAlister, 2002; Restrepo, Wettstein, Wittnebel, & Tracy, 2011).
Agostini and Singh (2009) stated that variations in the rate of PPCs may indicate the use of
multiple definitions and criteria to identify PPCs. O’Donohue (as cited in do Nascimento Junior
et al. 2014) defined PPCs as pulmonary abnormalities occurring in the post-operative period
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
4
which produce clinically significant identifiable diseases or dysfunction that negatively affect the
patient’s clinical course. Those complications include atelectasis, tracheobronchial infections,
pulmonary failure, and pneumonia. The contributing factors include post-anesthetic effects,
incision pain, and lying in bed for a prolonged time (do Nascimento Junior et al., 2014).
Different prophylactic methods for PPCs such as deep breathing exercises (DBE),
intermittent positive pressure breathing (IPPB), and physiotherapy are used, but incentive
spirometer is the choice for many hospitals in the US. The goal of using an incentive spirometer
in prevention of PPCs is to encourage the patient to mimic natural deep breathing, therefore
increasing lung volume. Most of the studies done on the use of incentive spirometry were
published in the journal of medicine (Rup et al. 2013). Even though incentive spirometry (IS) has
been used prophylactically since 1972, its efficacy is still controversial and many studies
questioned if it is the best preventative therapy compared to other PPCs therapies (do
Nascimento Junior et al. 2014). Rupp et al. (2013) remarked about the lack of studies or
comprehensive literature reviews on the use of IS in the journals of nursing, despite nurses being
primarily the ones who teach patients how to use IS. This lack of literature should be a
motivating factor for nurses to get involved in research in order to find out the best methods to
prevent PPCs; so that nursing decisions are made based on the most current evidences. The
nurses should not leave the realm of research to others only, especially concerning researches
that may affect their decision making.
Methodology
The methodology used in searching for evidences to answer the clinical question was
searching CINAHL, PubMed, and Cochrane Library databases. The words used for the search
were “incentive spirometry” or “postoperative” or “post-operative” or “post-surgical” or "after
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
5
surgery" or "following surgery"or “no treatment” or “other methods”. The search was limited to
2009-2014. In the CINAHL database, the search was also limited to “any author is a nurse”.
The search was initially limited to nursing research only because this paper is being
written for the class NURS 350 Research in Nursing. Moreover, nurses should be much
interested in research done by other nurses because they share the same scope of practice. Nurses
understand the challenges that they face in their practice while trying to make decisions based on
current evidence-based practice. If nurses do research to address clinical questions, they will
tackle the questions in a different way than other health professionals because they understand
those clinical questions from experience in the practice, therefore making their input even more
significant to other nurses.
However during the search, it became evident that they are not many researches on
incentive spirometry, and for this reason the search limit was expanded to include research from
other health professionals. Most of the researches that were found are old comprising research
done from 1980 to 2000. This lack of current research on how to prevent PPCs using incentive
spirometer or other therapies should drive the nurses as well as other health care professional to
do more research on the subject.
Discussion of Literature.
The discussion will be done on three articles separately, but in the end other articles will
be considered in order to make a decision concerning the clinical question.
Incentive Spirometry in Postoperative Abdominal/Thoracic Surgery Patients
The article being discussed (Rupp et al. 2013) is from a peer-reviewed journal (AACN
Advanced Critical Care) written by nurses. The main subject of the study was to ascertain the
efficacy of incentive spirometer in prevention of PPCs in post-operative abdominal/thoracic
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
6
surgery patients. Rupp et al. indicated that there was a lack of studies or comprehensive literature
reviews on this topic in nursing journal. This article is not a study by itself, but rather a systematic
review on the use of IS. Rupp et al. (2013) did they review so that nurses can have recommendation
on the use of IS from other nurses. The problem investigated was to compare IS and other therapies
as preventative methods for PPCs. The purpose of this review was to analyze the current literatures
at the time from research of high level of evidence in order to make recommendations that are
evidence-based for the benefit of other nurses (Rupp et al. 2013). This review analyzed four
systematic reviews, five articles, and one clinical practice guideline. Many of the studies in the
reviews and articles were randomized controlled study, therefore making them a high level of
evidence. The review team did not have any conflicts of interest concerning the project. Each
member of the review team reviewed the articles individually and then the whole team came
together to discuss and analyze the articles. This article did not use any statistics because it is a
systematic review.
Rupp et al. (2013) concluded that compared to other PPCs prophylactic methods IS was
effective only as the other prophylactic methods. It was concluded that all prophylactic methods
for PPCs including IS are better at preventing PPCs compared to no treatment. The results of the
review answered the question that was analyzed, are consistent with other similar reviews, and
they were very easy to understand. The strengths of this review stem from the level of analysis
used in evaluating each reviewed article. The review used a multidiscipline review team to discuss
the reviewed articles in order to view them from different viewpoints. The limitation of the review
was that most of the articles reviewed came from the journal of medicine. Rupp et al. (2013) made
a point that the absence of literature in journals of nursing excludes the perspective of nurses who
are the primary user of IS in helping patient prevent PPCs. The other limitation of the review was
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
7
that there was a lack of specific exclusion and inclusions criteria for the population studied, as well
as the criteria used in the measurement of outcomes. There was also a lack of information on how
long or how many repetitions were done on the different PPCs therapies. It would be beneficial to
use IS along with other prophylactic methods to prevent PPCs, but nurses must be cautious so that
the patient is overwhelmed by many different methods.
Incentive spirometry for prevention of postoperative pulmonary complications in upper
abdominal surgery
The article being reviewed (do Nascimento Junior et al. 2014) is a systematic review from
the Cochrane library. The main subject of the review was to analyze the efficacy of IS compared
no treatment or to other prophylactic methods PPCs in abdominal surgery patients. There is still
controversy about clinical efficacy of IS for prevention of PPCs, for this reason the review was
done in order to analyze its efficacy. The problem that was investigated is the efficacy of the
different methods used to prevent PPCs in patient who underwent abdominal surgeries. “The
primary purpose of the review was to assess the effect of incentive spirometry (IS), compared to
no such therapy or other therapy, on postoperative pulmonary complications and mortality in
adults undergoing upper abdominal surgery.” The secondary purpose to ascertain effects of IS, no
therapy or other therapies on adverse events, and spirometric parameters in adults undergoing
upper abdominal surgery. The population in the studies reviewed consisted of patient undergoing
abdominal surgeries, as well as laparoscopic procedures from age 18 and up. The review also
included patient with co-morbidity such as preexisting pulmonary conditions, smoking, and obese
individuals. Patients who developed other complications not related to pulmonary functions were
also included in the material reviewed. The literature reviewed spanned from year 1966 to 2013
from different database including, Cochrane Library, MEDLINE, EMBASE, LILACS, and
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
8
CINAHL. Two authors independently analyzed selected literatures and then came together to
resolve any disagreement in meetings. The level of evidence in this article is high because it is a
systematic review. The review assessed for risk of bias, heterogeneity, reporting bias as well as
sensitivity analysis in order to determine the cause of heterogeneity and the strength of the results.
Since this article is a systematic review, there was no statistical test performed. According to
do Nascimento Junior et al. (2014) “There is low-quality evidence regarding the lack of
effectiveness of incentive spirometry for prevention of postoperative pulmonary.” The results
answered the question under study and were similar to those of other reviews in some respects.
There were no significant statistical differences when IS was compared to no therapy or the other
therapies in preventing PPCs. The review indicated that many of the study included in the analysis
had methodological quality that was poorly reported, therefore making it hard to analyze. It was
difficult to assess the bias classification because it was unclear, and the studies done did not include
information on how well the patient complied with the prescribed method for the prevention of
PPCs. Given the percentage of PPCs after abdominal surgery (18% to 87%) and the lack of
evidence for efficacy of IS in PPCs prevention, this systematic review point out again that there is
a need to conduct well-designed randomized trials in order to study the different methods that are
used in the prevention of PPCs
Impact of Early Incentive Spirometry in an Enhanced Recovery Program After
Laparoscopic Donor Nephrectomy
The study being discussed (Rollins et.al, 2013) is a peer-reviewed journal (Transplantation
Proceedings, 2013) written by staff from Nottingham City Hospital, Nottingham, UK. The main
subject of the study was to evaluate the benefits of early use of incentive spirometer (IS) in the
prevention of chest infection in patients undergoing laparoscopic donor nephrectomy. Rollins et
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
9
al. indicated that there not enough research on the effect of IS on the incidence of chest infection
after laparoscopic abdominal surgery is not well-established, which is why this research is
warranted. The problem investigated was the effects the early use of IS in prevention of infections
in patients undergoing laparoscopic abdominal surgery. The purpose of the study was to “assess
the impact of early incentive spirometry on the incidence of chest infection in patients undergoing
laparoscopic donor nephrectomy” (Rollins et al., 2013, p.1351). The study was a retrospective in
some parts, and the population included patient who underwent laparoscopic donor nephrectomies
in Nottingham City Hospital, Nottingham, UK. This study shows a low level of evidence because
it retrospective in nature in some parts. A threat to validity (instrumentation changes) arises in this
study. A retrospective review of all medical and nursing notes and imaging were performed with
particular focus on the postoperative course. The study does not address concerns that the doctors,
nurses,, radiologists may not have followed the same procedure in documenting post-operative
course in the patients from 2008-2010. The study does not also indicate what kind of images were
assessed or if the same machine was used to take all the images. Statistical analysis was performed
using GraphPad Prism v5. “Descriptive statistic was used to differentiate the characters from
different patients; Chi-square analysis to evaluate the incidence of chest infection against presence
or absence of IS, and the t-test for detecting differences between continuous variables for the two
groups.” (Rollins et al., 2013, p. 1352). Both the t-test and the Chi-square are appropriated for
nominal data. Rollins et al. suggest the use early use of IS reduces the incidence of infections in
people who underwent laparoscopic donor nephrectomy. However, it was also underscored that
randomized, controlled trials are needed to study this subject more.
Other studies
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
10
Agostini and Singh (2009) concluded in their systematic review that there may be some
benefit in using IS in order to achieve lung re-expansion following major thoracic surgery. Their
review also indicated that physiotherapy without the use of IS seems to be effective after thoracic
surgery compared with not treatment. There exist different type of IS used in practice, and they
work using different mechanisms. However, it has not been shown if there is a difference in the
outcome when different ISs are used. This is also an area that can be explored in the future
studies by nurse researchers. Stannard (2013) conducted a systematic review about the benefit of
IS in preventing PPCs after coronary artery bypass (CABG). The review concluded that “there
was no difference between IS and the other therapies such as continuous positive airway pressure
mask therapy (CPAP), bilevel positive airway pressure (BiPAP) mask therapy, intermittent
positive pressure breathing (IPPB), and physiotherapy.” It was also noted that the studies
analyzed in this review were small in numbers and variable, making it difficult to do analysis. It
was suggested that this variability in practice is a result of lack of a common standard for
conventional chest physiotherapy. The review noted “The best comparison would be to use a
placebo or no intervention along with the total absence of conventional chest physiotherapy as a
control. However, this is usually considered to be unethical” (p. 238).
Restrepo et al. remarked that use of physiotherapy including IS in prevention of PPCs is
still controversial. It was indicated that the effects of IS may be different depending on patient
selection, following instructions careful, or supervision during respiratory training.
After reviewing different studies and systematic reviews; it is evident that there is a lack of
current research on the benefit of IS or other therapies used in the prevention of PPCs. The lack
of current research should be the driving force for nurses to get involved in quality research in
order to ascertain the benefit of IS as well as the other therapy used in PPCs prevention so that
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
11
the nurse can make evidence-based decisions. Nurses should realize that their input in the
research may offer a different perspective that other healthcare professional researchers may not
have. For example, they may be able ascertain by their experience how different patients feel
about the use of different therapies, as well as their likes and dislikes about different therapies.
Given the current evidence, IS should be used in conjunction with other therapies in the
prevention of PPCs, but nurses and other health professionals should be conscious about
differences in patients depending on the type of abdominal or thoracic surgeries done one them.
Significance to Nursing
As with any other sciences, nursing knowledge continues to grow. Acquiring this
knowledge is achieved through carefully designed research studies that seek to answer different
clinical questions that nurses face in their practice. According to ANA scope and standards
(2012), “ Nurses are expected to provide care that is driven by evidence-based practice (EBP) to
ensure optimal clinical outcomes and quality of life” Without EBP patients would not be
receiving the best quality of care, and their safety would be compromised. However, the
existence of EBP does not always mean that the patient safety is assured, nor the patient receive
the best quality of care. Sometimes nurses may resist change and may still use outdated
methods. As noted in ANA’s scope and standards of practice, it was found that some of the
nurses lack confidence in their skills to evaluate the quality of research and lack confidence to
implement change in the practice setting. Nurses must learn to appreciate EBP and be willing to
learn new skills in order to offer impeccable service to their patients. They must be willing not to
resist the change, but willing to embrace it and encourage one another in applying EBP in the
clinical setting.
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
12
According to (Cronenwett et al., 2007), both quality and safety are very important in the
patient care. To ensure patient’s safety, the nurse seeks to “minimizes risk of harm to patients
and providers through both system effectiveness and individual performance.” While ensuring
the safety of patient, nurses must “use data to monitor the outcomes of care processes and use
improvement methods to design and test changes to continuously improve the quality and safety
of health care systems.” Since it’s sometimes hard for nurses in practice to adapt to changes and
apply EBP in the clinical setting, nursing students should learn how to critically evaluate new
research while still in nursing school. If this is accomplished, new nurses can influence those
who are already in practice and instill in them the love to strive for EBP in the clinical setting.
According to Hickey (2010, p. 187) the professional registered nurse has a responsibility to
perform evaluations activities in order to maintain and improve performance. This is a good
value to espouse because it build accountability and lead to nurses in identifying strengths, as
well as weakness. Nurses can not ensure the safety and quality of patients without the support
from the leadership and management departments. The management must be willing to work
with the nurses, to help them in identifying EPB that will contribute to the achievement of safety
and quality of patients. Through policies, regulations, training, and enough resources to support
nurses on the floor, the management can make a huge impact in helping nurses in providing care
that is safe and of good quality to the patient
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
13
References
Agostini, P., & Singh, S. (2009). Incentive spirometry following thoracic surgery: what should
we be doing? Physiotherapy, 95(2), 76–82. doi:10.1016/j.physio.2008.11.003
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., … Warren, J.
(2007). Quality and Safety Education for Nurses. Nursing Outlook, 55(3), 122–131.
doi:10.1016/j.outlook.2007.02.006
Do Nascimento Junior, P., Módolo, N. S. P., Andrade, S., Guimarães, M. M. F., Braz, L. G., &
El Dib, R. (2014). Incentive spirometry for prevention of postoperative pulmonary
complications in upper abdominal surgery. The Cochrane Database of Systematic Reviews,
2, CD006058. doi:10.1002/14651858.CD006058.pub3 upper abdominal surgery. Cochrane
Database of Systematic Reviews, Issue 2. Art. No.: CD006058. DOI:
10.1002/14651858.CD006058.pub3.
Guimarães, M., El Dib, R., Smith, A., & Matos, D. (2014). Incentive spirometry for prevention
of postoperative pulmonary complications in upper abdominal surgery. Cochrane
Database of Systematic Reviews, (2), doi:10.1002/14651858.CD006058.pub2
Hickey (2012). Professional Practice Evaluation. K. M. White., & A. O'Sullivan . The Essential
Guide to Nursing Practice. Applying ANA’s Scope of and Standards in Practice and
Education. Silver Spring, MD. American Nurse Association
Overend T.J., Anderson C.M., Lucy SD, Bhatia C, Jonsson BI, &Timmermans C. (2001) The
effect of incentive spirometry on postoperative pulmonary complications. Chest; 120
(3):971–8.
THE USE OF INCENTIVE SPIROMETER AFTER SURGERY
14
Restrepo, R. D., Wettstein, R., Wittnebel, L., & Tracy, M. (2011). Incentive Spirometry:
2011. Respiratory Care, 56(10), 1600-1604. doi:10.4187/respcare.01471
Rollins, K. E., Aggarwal, S., Fletcher, A., Knight, A., Rigg, K., Williams, A. R., &
Bhattacharjya, S. (2013). Impact of early incentive spirometry in an enhanced recovery
program after laparoscopic donor nephrectomy. Transplantation Proceedings, 45(4),
1351–1353. doi:10.1016/j.transproceed.2013.01.036
Stannard, D. (2013). Incentive Spirometry for Preventing Pulmonary Complications After
Coronary Artery Bypass Graft. Journal of Perianesthesia Nursing, 28(4), 236-238.
doi:10.1016/j.jopan.2013.05.003