Running head: Preventing Postoperative Pulmonary Complications
Preventing Postoperative Pulmonary Complications
Danielle D Grant
University of New Hampshire
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Preventing Postoperative Pulmonary Complications
Preventing Postoperative Pulmonary Complications
Title: In postoperative patients, is including incentive spirometry therapy after surgery more
effective in preventing pulmonary complications compared to patients who do not include
incentive spirometry therapy?
Background and Rationale
After surgery, patients are at higher risk for pulmonary complications. Complications can
include pulmonary embolism, atelectasis, and pneumonia. Factors leading to these complications
are pain and increased bed rest due to immobility. Pulmonary complications occur due to lack of
lung inflation after surgery from a change to shallow breathing pattern, prolonged recumbent
positioning, and temporary diaphragmatic dysfunction. Clearance of mucus and a decreased
effectiveness of coughing are also impaired in postoperative patients which increases the risk of
retained secretions.
Respiratory physiotherapy after surgery aims to promote maximal inspiration in order to
expand the collapsed alveoli and limit secretions. An incentive spirometer is a device used to
achieve and maintain maximal inspiration. Other interventions include taking a deep breath and
holding it for 3-5 seconds as well as coughing. Intervention is necessary to prevent such
complications after surgery, but the clinical efficacy of incentive spirometry is not completely
clear. Hospitals are still using this device, yet could coughing and deep breathing produce the
same results? Clinical research explores the best implantation in preventing postoperative
pulmonary complications.
Search Methods
During the process of finding evidence, the main database used was CINAHL, provided
by the UNH Library. CINAHL includes full text for nursing and allied health journals. Although
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Preventing Postoperative Pulmonary Complications
the search engine Google for basic definitions, all evidence was established from CINAHL. In
the search, the key words "postoperative" and "incentive spirometer." The search was limited to
English only, articles published since 2000, and full text available. Three citations were
identified in establishing my evidence. Inclusion data were articles published after 2000 that
focused on postoperative patients from cardiac or abdominal surgeries exploring the use of
incentive spirometry to prevent pulmonary complications. Other types of surgeries were not
included in this study. Articles that reviewed the effects of arterial blood gas and pulmonary
pressure levels without an overview of pulmonary complications were also excluded.
Critical Appraisal of the Evidence
The first article, “The Effect of Incentive spirometry on Postoperative Pulmonary
Complications,” is a systematic review of evidence examining the use of incentive spirometry for
the prevention of postoperative pulmonary complications. The search consisted of articles from
MEDLINE, CINAHL, HealthSTAR, and Current Contents databases. The review accepted 46
articles that included 26 randomized controlled trials, 9 quasi-randomized controlled trials, 4
cross-over designs, 4 case series, 1 prospective cohort study, 1 retrospective case series, and 1
meta-analysis. Each study was clinically appraised by one of three pairs of team members who
each separately completed a Clinical Appraisal Form (CAF). The key areas on the CAF
examined information on study purpose, subject characteristic, study design, and results. Each
pair met to reach a consensus before presenting to the entire review team for discussion and
agreement. The team was unable to accept conclusions in 35 of the 46 papers due to multiple
methodolic problems. Of the 11 remaining articles, only one supported the proposed theoretical
benefits of incentive spirometry. Due to this, the overall evidence did not support incentive
spirometry for preventing postoperative pulmonary complications following cardiac or upper
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Preventing Postoperative Pulmonary Complications
abdominal surgery. Bias was minimized in the study by using an extensive search strategy along
with independent review of the validity of each study using a standardized CAF followed by an
overall consensus. Three studies evaluated the "short-term" effects of incentive spirometry by
looking at a single treatment. They failed to show any benefit on diaphragm function, PaO2, or
end-expiratory transpulmonary pressure following cardiac surgery. The other eight studies
investigated the effects of incentive spirometry as either a stand-alone treatment or an adjunct to
treatment. Four of the studies dealt with postoperative cardiac patients while the other four
focused on abdominal surgery. Following cardiac surgery, there is little evidence to support the
use of supervised incentive spirometry as either a stand-alone or adjunct therapy. Three of the
studies involving abdominal surgery also indicated no support. One supported use of incentive
spirometry, however, the authors noted that it included both upper and lower abdominal surgery
and there is minimal risk for pulmonary complications in lower abdominal surgery. The
limitations of the review were articles retrieved were English only, possibly lacking relevant
studies. Also supplements of relevant journals for abstracts not published as peer-reviewed
articles were not searched and all authors were not contacted to clarify information not clearly
available.
The objective of the second article, “Incentive spirometry for prevention of postoperative
pulmonary complications in upper abdominal surgery,” was to assess the effect of incentive
spirometry compared to no such therapy on all-cause postoperative pulmonary complications and
mortality in adult patients admitted for upper abdominal surgery. The study included randomized
controlled trials of incentive spirometry in adult patients admitted for any type of upper
abdominal surgery. Two authors independently assessed trial quality and extracted data from 11
studies with a total of 1160 patients. Three trials looked at the effects of incentive spirometry
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Preventing Postoperative Pulmonary Complications
with no respiratory treatment. Two trials compared incentive spirometry with deep breathing
exercise. Two other trials compared incentive spirometry with other chest physiotherapy. The
study found no evidence regarding the effectiveness of the use of incentive spirometry for
prevention of postoperative pulmonary complications. There were no language restrictions which
allowed for all relevant studies to be examined. The study included patients undergoing
laparoscopic procedures which may be a weakness due to the lower risk of pulmonary
compilations. Many trials were of only moderate methodological quality and did not report on
compliance with the prescribed therapy.
The third article discussed a prospective observational study over eight months of
patients attending the surgical high dependency unit following open abdomen or open chest
surgery. During the first four months, the patients in the hospital received standard chest
physiotherapy consisting of five deep breaths. Each breath included an inspiratory hold and sniff
followed by a supported cough. The patients in the hospital during the final four months received
standard chest physiotherapy with deep breaths being performed via and incentive spirometer
rather than inspiratory hold and sniff. There were a total of 111 patients in the no incentive
spirometry group and 117 patients in the incentive spirometry group. The average length of stay
on the high dependency unit was 4 days in the group without incentive spirometry and 3.1 days
with incentive spirometry. According to the study, 17% of patients in the no incentive spirometry
group developed postoperative pulmonary complications versus 6% in the incentive spirometry
group. Since the study was designed as an observational study, interpretation of complications is
open to observer bias. Length of stay should be proportional to the rate of complication, yet there
was minimal significant difference in that area. This study concluded that a decreased incidence
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Preventing Postoperative Pulmonary Complications
of pulmonary complications postoperatively is demonstrated when incentive spirometry is added
to physiotherapy.
Evidence Synthesis
From the evidence I have collected on the effectiveness of using incentive spirometry to
prevent postoperative pulmonary complications, I have concluded that there is no significant
difference. Although incentive spirometry is designed to encourage the patient to take long, slow,
deep breaths to increase lung expansion, the evidence does not supportive its clinical efficacy
compared to other physiotherapies. There is no evidence signifying that incentive spirometry is
harmful to postoperative patients, however, deep coughing and breathing seem to be just as
effective. In the first review, the study that supported the use of incentive spirometry also looked
at lower abdominal surgeries which already have a lower risk of complications. This may have
skewed the data. Although the third study also supported the use of incentive spirometry, the
postoperative pulmonary complications was increased by only 11%. It also stated that that
physiotherapist were requested to see patients as emergency contacts less often in the incentive
spirometry group, but this failed to achieve statistical significance. Overall I do not believe there
is enough evidence to support the clinical decision that incentive spirometry significantly lowers
the risk of pulmonary complications in postoperative patients.
Clinical and Research Recommendations
Based on my critical appraisal of the evidence, nursing practice should implement the use
of deep breathing and coughing as much as possible during postoperative care. No significant
evidence supports the idea that incentive spirometry is more effective in preventing pulmonary
complications. This does not, however, determine that it will cause any harmful side effects to
the patient. Further research requires trials of high methodological to continue to define any
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Preventing Postoperative Pulmonary Complications
benefits from incentive spirometry. As long as patients are taught the effective method of
coughing and deep breathing and encouraged to do so regularly, there risk for pulmonary
complications is no greater than those using incentive spirometry therapy. Clinical practices need
to be sure correct methods are instituted and performed effectively.
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References
Overend, T. J., Anderson, C. M., Lucy, S., Bhatia, C., Jonsson, B. I., & Timmermans, C. (2001).
The Effect of Incentive Spirometry on Postoperative Pulmonary Complications. Chest,
120(3), 971.
Guimarães, M., El Dib, R., Smith, A., & Matos, D. (2009). Incentive spirometry for prevention
of postoperative pulmonary complications in upper abdominal surgery. Cochrane
Database Of Systematic Reviews, (3), doi:10.1002/14651858.CD006058.pub2
Westwood, K., et al. "Incentive Spirometry Decreases Respiratory Complications Following
Major Abdominal Surgery." Surgeon (Edinburgh University Press) 5.6 (2007): 339-342.
Academic Search Alumni Edition. Web. 11 Dec. 2013.
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