PREVENTING PULMONARY COMPLICATIONS
Preventing Pulmonary Complications
Brianna Boden
University of New Hampshire
1

PREVENTING PULMONARY COMPLICATIONS 2
Clinical Question
How does the use of incentive spirometers compare to the use of deep breathing exercises in the prevention of respiratory infections in immobilized, post-op hospitalized patients?
Background
Pulmonary complications following surgical procedures are one of the primary difficulties and concerns for patients requiring general anesthesia. According to recent statistics, nearly 40 percent of patients undergoing various procedures requiring general anesthesia develop pulmonary complications (Tedja & Gordon, 2013). It was noted that hospital-acquired pneumonia accounts for over 15% of all hospital acquired infections after general anesthesia, which cause further medical complications for the patient (Tedja
& Gordon, 2013). The expected length of stay for a patient who acquires nosocomial pneumonia is prolonged by 7 to 9 days. Estimates are that the hospital costs for these patients increase by nearly $40,000 (Tedja & Gordon, 2013) due to this acquired infection. One reason that the postsurgical rate of pulmonary complications is so high is that many patients remain immobilized for prolonged periods of time following surgery.
This immobilization can lead to various degrees of collapsed alveoli, known as atelectasis, which is triggered by the patient not expanding their lungs. The alveoli remain collapsed and fill with exudate that allows for bacteria to grow, and therefore sets the stage for potential pulmonary infection. Other pulmonary complications that may occur post-operatively are respiratory failure, bronchospasm, prolonged mechanical ventilation, and bronchitis. Therefore, the nurse’s role in teaching and implementing methods to enhance the prevention of pulmonary complications is essential.

PREVENTING PULMONARY COMPLICATIONS 3
Nursing interventions do not guarantee that a patient who is taught techniques or methods to minimize pulmonary complications will be free from infection. A common nursing intervention that is demonstrated and taught to patients following surgery is the correct use of an incentive spirometer. The incentive spirometer is a device that promotes lung expansion and deep breathing, which can help prevent atelectasis. The patient exhales deeply and then places the device up to his or her mouth—forming a tight seal around the mouthpiece. The patient then inhales slowly and as deeply as possible to raise the device indicator, and then holds his or her breath for 3-5 seconds. This pressure helps open the alveoli within the lungs. The indicator on the spirometer aids in measuring how well the patient’s lungs are functioning, the quality of the patient’s inhale, and progress of the patient. This process should be repeated approximately 5-10 times every hour or as ordered by the provider. Without any intervention, the patient is at an increased risk for pulmonary infection, which can prolong the patient’s hospital stay, increase the length of poor health, and increase the cost of the patient’s care.
The use of an incentive spirometer has been the benchmark for preventing pulmonary complications within postsurgical patients. Although questions about whether the cost of the incentive spirometer is worth the outcome, the device continues to be the primary prophylactic intervention. While deep breathing exercises can be taught freely to patients, the average cost for an incentive spirometer ranges from $10 to $80 (Allegro
Medical). If the incentive spirometer is provided to most patients following surgery, the costs quickly multiply. The purpose of this research is to compare the effectiveness of incentive spirometry versus deep breathing exercises in post surgical patients who had general anesthesia. This research will analyze if the cost of the incentive spirometer

PREVENTING PULMONARY COMPLICATIONS 4 validates its worth by demonstrating lower pulmonary complications when compared to deep breathing exercises alone.
Search for Evidence
While conducting research pertaining to this topic, the CINAHL database was searched to find studies related to the research. To narrow down the results, only articles that were peer-reviewed, written in the English language, conducted within the last 20 years, publication type: journal article, and evidenced-based were considered for use in this paper. There were no limitations to the age groups allowed in the studies. The terms that were used to find the studies were “incentive spirometer” and “deep breathing,” which was then redefined to “incentive spirometer” and “breathing exercises.” Articles that only pertained to the effectiveness of deep breathing exercises or incentive spirometry individually were not included, as they were not useful in answering the clinical question.
Evidence
The article To Compare the Immediate Effect of Deep Breathing Exercise and
Incentive Spirometry on ABG after Mitral Valve Replacement Surgery reported on a study completed to help respiratory therapists in Intensive Care Units implement the most effective method to reduce pulmonary complications in patients undergoing cardiac surgery. The study performed was a randomized clinical trial that placed 32 patients who received a Mitral Valve replacement into two different study groups. The patients were either assigned to perform deep breathing exercises or use incentive spirometry, with the
ABG’s of these patients measured before and after the pulmonary therapy techniques
(Rizwan, Jalwan & Mukherjee, 2012). The findings of the study revealed that those

PREVENTING PULMONARY COMPLICATIONS 5 patients who used deep breathing exercises had a significant increase in oxygen in the blood and oxygen saturation. The patients who used the incentive spirometer showed lower rates of oxygen in the blood. This study indicates that with the basic use of deep breathing exercises, oxygen is more easily transported into the bloodstream. In regards to the prevention of pulmonary complications, it was found that deep breathing exercises and the use of the incentive spirometer were not significantly different. A downfall of this study was that only 32 patients were studied, making the population small and increasing the influence of possible extraneous variables. The strength of this study was that the participants all had similar demographics. All the patients were of similar age, weight, height, BMI, and sex. This allowed for the findings to limit any extraneous variables, and the results to be more accurate.
A study was performed that examined the effects of deep breathing exercises and incentive spirometry with patients who had undergone coronary artery bypass grafting surgery. The study, A Comparative Study on the Effects of Incentive Spirometry and Deep
Breathing Exercise on Pulmonary Functions after Uncomplicated Coronary Artery
Bypass Grafting Surgery, used a randomized clinical trial and placed 32 patients into two groups of either deep breathing exercises or use of incentive spirometers. The patients participating in this study came from a convenience sample and were between the ages of
38 and 68, all of which were having an elective coronary artery bypass surgery. The patients in this study were all adults with similar weight, height, and BMI. This fact allowed for limited variability among the patients. While the small sample size allowed for each participant to be closely monitored, the small number of participants weakens the study and limits the ability to draw strong conclusions from the findings. The results

PREVENTING PULMONARY COMPLICATIONS 6 of this study found that the only difference in the two groups were that those who performed deep breathing exercises had better ABG’s than those who used the incentive spirometer ( Mueenudheen, Moiz & Gupta, 2012) . From this study, it was determined that incentive spirometry was no more effective for increasing pulmonary functioning than deep breathing exercises, and the ABG was actually better in the patients practicing deep breathing exercises. The findings indicate that incentive spirometry and deep breathing had the same results regarding pulmonary functioning in patients recovering from coronary artery bypass grafting surgery.
Incentive Spirometry Versus Routine Chest Physiotherapy for Prevention of
Pulmonary Complications after Abdominal Surgery is a study that examined 876 patients following abdominal surgery. The study was a clinical trial that evaluated whether conventional chest physiotherapy that consisted of deep breathing exercises, or the use of incentive spirometry was more effective in preventing pulmonary complications. The patients placed in the group that used the incentive spirometer were monitored to ensure that the device was used for 5 minutes during every hour that the patient was awake. The other group of patients who received the conventional chest physiotherapy was educated on how to perform the deep breathing exercises, and was asked to complete these exercises every hour. The results of the study determined that the difference of incidence of pulmonary complications was not significant between the two groups (Hall, Tarala,
Harris, Tapper & Christiansen, 2012). The findings of this study indicate that both incentive spirometry and conventional chest physiotherapy are effective methods in reducing pulmonary complications for patients following abdominal surgery. The strength of the study was the number of patients involved so the sample group was larger

PREVENTING PULMONARY COMPLICATIONS 7 than many other studies. The large sample size strengthened the data to show that in larger populations the data was similar to other studies. A weakness to this study was that the patients involved were not similar demographically. The patients in the study only had to be over the age of 18 and recovering from an abdominal surgery. This weakens the data because it allows for questioning of extraneous factors that could affect the results.
Another study that explored the prevention of pulmonary complications in highrisk patients after coronary artery bypass surgery examined deep breathing exercises and incentive spirometry. The article, The Effectiveness of Incentive Spirometry with Physical
Therapy for High-Risk Patients after Coronary Artery Bypass Surgery, employed a convenience sample of 185 patients with chronic airflow limitations following Coronary
Artery Bypass Grafting surgery. The patients in the study were randomly assigned to receive only postoperative pulmonary physical therapy or postoperative pulmonary physical therapy with the added use of incentive spirometry. The postoperative pulmonary physical therapy included deep breathing exercises, secretion removal and mobility. The findings from the results indicate that there was no difference found in oxygen saturation, pulmonary infection, atelectasis, or hospital stay between the two groups (Crowe & Bradley, 1997). The results from this study reveal that incentive spirometry does not significantly improve patient outcome or patient progress when added to conventional pulmonary physical therapy. This study was conducted in 1997, which provides a historical perspective about the comparison between incentive spirometry and deep breathing exercises. The findings of this study are important but are not as current as the other studies reviewed, and nursing care is always evolving.
Although this article is a few years older than studies previously reviewed, it had similar

PREVENTING PULMONARY COMPLICATIONS 8 findings and conclusions. This strengthens the data by showing that studies over time found that the use of the incentive spirometer is no more effective in preventing atelectasis or improving lung function than deep breathing exercises.
Body of Evidence
Based on the evidence, findings, and conclusions from the studies reviewed, it is apparent that deep breathing exercises are equally as effective as incentive spirometry at preventing post-operative pulmonary complications. Rizwan, Jalwan, and Mukherjee conducted a study that reviewed 32 patients with the use of deep breathing or incentive spirometry and measured their arterial blood gases. This study revealed better oxygenation to the blood and oxygen saturation for those patients that performed the deep breathing exercises. Mueednudheen, Moiz, and Gupta compared the use of incentive spirometry and deep breathing among patients following CABG surgery. From this study it was determined that patients who used deep breathing had better pulmonary function scores. Another study by Hall, Tarala, and Tapper found that incentive spirometry was no more effective than conventional chest physiotherapy that included deep breathing exercises. The last study by Crowe and Bradley found that when incentive spirometry was added to chest physical therapy, there was no decrease in atelectasis. From the information and evidence gathered from recent studies, the easiest answer to the above
PICOT question is “No.” Incentive spirometry is no more effective in the prevention of pulmonary complications than deep breathing exercises. In some studies it was reported that deep-breathing exercises allow for better arterial blood gases and render no additional expense for a spirometer.

PREVENTING PULMONARY COMPLICATIONS 9
Recommendation
Nurses provide the greatest amount of direct care for the patient and are able to provide patients with the time needed for teaching and advocacy. Nurses are required to implement provider’s orders for the patient and it is also the nurse’s role to ensure that the inpatient is compliant with the treatment to prevent post-operative respiratory infections. It is often reported that patients are not compliant with respiratory therapy, therefore increasing their chances of having a pulmonary complication. Teaching patients deep breathing exercises allows for increased nurse interaction and communication. This teaching is an expense-free intervention, and allows the nurse to check on the patient frequently to ensure compliance with the deep breathing exercises. After analyzing the evidence, it is clear that the incentive spirometer is no more effective than conventional deep breathing exercises in decreasing pulmonary complications in post surgical patients.
From the evidence gathered in the considered studies, the benefits of the use of incentive spirometry as the primary intervention to prevent pulmonary complications may need to be further reviewed. Deep breathing exercises appear to provide equally effective results in lowering pulmonary complications in post surgical patients. Both interventions require patient education and cooperation. Although both interventions demonstrate similar results in the prevention of pulmonary complications, incentive spirometer requires a patient to use specialized equipment instead of focusing on simple deep breathing. Due to the cost of incentive spirometers, the use of deep breathing exercises would greatly decrease the cost of hospital stay for postsurgical patients.
Currently, incentive spirometers are still considered the gold standard for preventing post-operative pulmonary complications. Often patients are not compliant

PREVENTING PULMONARY COMPLICATIONS 10 with this intervention, therefore increasing the risk for hospital-acquired pneumonia or other pulmonary complications. Nurses need to reinforce the use of incentive spirometry or deep breathing exercises, and explain the risk for pulmonary complications without any prophylactic interventions. Teaching and providing clear and concise methods for deep breathing exercises and/or the use of incentive spirometry is crucial for the wellbeing of postsurgical patients who have undergone general anesthesia. Nurses also need to assess the post-operative patient frequently to observe for any symptoms that could indicate a pulmonary infection or complication.

PREVENTING PULMONARY COMPLICATIONS 11
References
AllegroMedical.com, Inc. (2014). Search Results: Incentive spirometer. Retrieved from: http://www.allegromedical.com/browse/browseProducts.do?searchPhrase=incenti ve+spirometer
Crowe, J., & Bradley, C. (1997). The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Physical
Therapy , 77 (3), 260-268. CINAHL Complete.
Hall JC; Tarala R; Harris J; Tapper J; Christiansen K. Incentive spirometry versus routine chest physiotherapy for prevention of pulmonary complications after abdominal surgery 1991 Apr (The Cochrane Controlled Trials Register (CCTR/CENTRAL)).
In: The Cochrane Library , Issue 1, 2012. Oxford: Update Software. Updated quarterly.
Mueenudheen, T., Moiz, J. A., & Gupta, V. (2012). A comparative study on the effects of incentive spirometry and deep breathing exercise on pulmonary functions after uncomplicated coronary artery bypass grafting surgery. Indian Journal Of
Physiotherapy & Occupational Therapy , 6 (`2), 63-67.
Tedja, R., & Gordon, S. (2013, November 1). Hospital–Acquired, Health Care–
Associated, and Ventilator–Associated Pneumonia. Retrieved December 2, 2014, from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/in fectious-disease/health-care-associated-pneumonia/

PREVENTING PULMONARY COMPLICATIONS 12
Rizwan, A., Jalwan, J., & Mukherjee, S. (2012). To Compare the Immediate effect of
Deep Breathing Exercise and Incentive Spirometry on ABG after Mitral Valve
Replacement Surgery. Indian Journal Of Physiotherapy & Occupational Therapy ,
6 (4), 12-17.