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Preventing Post-Operative Pulmonary Complications: Incentive Spirometry vs. Standard
Rehabilitation
Kristen Kubik
Ferris State University
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Abstract
The use of an incentive spirometer to help prevent post-operative pulmonary complications
(PPC) has been standard. However, research may not support or justify its use. This paper looks
at the research surrounding the use of an incentive spirometer to help prevent PPCs. It compares
the use of an incentive spirometer during rehabilitation with having the patient only performing
rehabilitation (physical and/or occupational therapy).
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Preventing Post-Operative Pulmonary Complications
The purpose of this paper is to review and interpret current research on the use of the
incentive spirometer in preventing post-operative pulmonary complications (PPCs). I will use the
knowledge gained from these studies to support nursing decisions concerning the use of the IS.
This paper shows how knowledge and review of research is used in the personal and professional
practice of a nurse (Ursuy, 2014).
PICOT
An incentive spirometer (IS) is a tool used to keep the alveolar sacs in the lungs open
longer, promoting gas exchange and strengthening of the lungs. Often, post-operative patients
feel too weak to take deep breaths or are in too much pain. This causes them to subconsciously
take shallow breaths, causing gas and fluid retention in the lungs. Traditionally, physicians
prescribe and nurses promote the use of an incentive spirometer after operations to help prevent
pulmonary complications such as pneumonia. They instruct their patient to use the device every
one to two hours ever day while awake.
Because patients dislike constantly performing this exercise and nurses tire of being a
constant annoyance to their patients, the necessary use of the IS is in question. Many nursing
blogs cover this topic with nurses expressing their frustration with having to remind their patient
every hour all day long. One blogger wrote, “How do you get your patients to actually use their
incentive spirometer without having to tell them to every hour?” (angelsr28, 2010). Another
responded, “Seriously, you can only make an adult do so much,” (onetiredmomma, 2010).
The frustration caused by the incentive spirometer is what fueled my investigation into its
effectiveness. After finding that the research did not prove the IS effective, I decided to make
this the topic for my PICOT paper. PICOT is an acronym used to properly format clinical
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questions. The letters stand for: patient or population, intervention or interest area, comparison
intervention or current practice, outcome desired, and time to achieve outcome (the final letter is
optional) (Nieswiadomy, 2012, p.282-283). This is the format I will use to answer my question
on the use of the IS.
Population: Post-operative patients enrolled in rehabilitation therapy (physical and/or
occupational).
Intervention: The use of the incentive spirometer as directed by their nurse or physician.
Comparison: Patients who are in therapy (physical or occupational) but are not using the
incentive spirometer.
Outcome: The use of the incentive spirometer as an effective tool in preventing PCCs is or is not
effective.
PICO Question: Does the use of an incentive spirometer reduce pulmonary complications in
post-operative patients that are enrolled in physical and/or occupational therapy compared with
patients who only perform the scheduled therapies?
Approach
I began searching through research by using the phrase “incentive spirometer and postoperative complications.” Many articles resulted but very few were nursing research. Of the
articles I found that pertained to my PICO question, only one was nursing research. I found that
this is a topic that surgeons and respiratory therapists are conducting research on the most and
realized that I would have to include all types of research (not limit it to nursing) in order to have
my PICO question properly answered. The nursing research results all covered instructing a
patient on the use of incentive spirometry, not whether or not it should be used in the first place.
Thus, I expanded my search to include all medical research, not only nursing.
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First, I entered “incentive spirometer and post-operative complications” and “incentive
spirometer preventing pulmonary complications” into PubMed. The former search pulled up nine
articles, none being relevant to the PICO question. The latter did not pull up any results
whatsoever. Next, I tried using CINAHL and Cochrane Library, both resulting in roughly 35
articles that pertained to my PICO. Based on year of publication, source, method, and any
concerns with research I narrowed the results down and chose five articles that met the
qualifications. All but one article were Level 1 Evidence as they are reviews of randomized
control trials pertaining to the PICO question (Melnyk & Fineout-Overholt, 2011). One article
was a report on current research that has been conducted on the use of the incentive spirometer.
According to Melnyk and Fineout-Overhold, Level 5 Evidence is a review of descriptive and
qualitative studies (2011). Even though this last article is considered Level 5 Evidence, I still
chose to use it because of its accurate and scientific analysis of the current research available on
the topic. The article also summarized the different options in trying to prevent post-operative
pulmonary complications.
As stated above, there were issues with many articles that disqualified them from being
used towards answering PICO question. Many of the sample sizes were small (less than 200
patients studied) thus not showing an accurate depiction of the results. Another issue presented in
the majority of studies was the inability to accurately assess whether the patient is properly using
their incentive spirometer. The studies did not mention whether thorough patient education was
given on IS administration nor was anything mentioned on whether the nurses were observing
the patient and how they used their device. The IS is designed to be used ten times every one to
two hours while awake. These studies were conducted in a hospital setting where nurses are
extremely busy and unable to go to each patient’s room every one to two hours to operate their
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IS with them. Thus, the results can never be one hundred percent accurate. If a study did not
even mention this issue, it was eliminated. Additionally, there were many articles that I was
unable to find full access to. The advanced search engines used would bring up abstracts on all
articles found but retrieving the full text was sometimes unsuccessful. Below, I will analyze
three of the five articles that answer my PICO question and summarize the results.
Review of Evidence
Article One
Incentive Spirometry for Preventing Pulmonary Complications After Coronary Artery
Bypass Graft by Dr. Stannard, published in the Journal of PeriAnesthesia Nursing, addresses the
question of whether incentive spirometry (IS) is comparatively effective to other methods in
preventing post-operative pulmonary complications (2013). There were nine randomized control
trials that were included in this review. Two independent people reviewed each trial searching
for whether it should be included or not in the study. Pulmonary complications that were chosen
as being a post-operative complication were: atelectasis, acute respiratory infection, and total
mortality caused from a respiratory issue (2013, p. 236). Other parameters being monitored
included but not limited to vital capacity, respiratory muscle strength, number of post-operative
days in the hospitals, perceived quality of life and functional capacity (2013, p 236). There were
a total of 592 patients studied, none being pediatric (all being older than 18 years of age). All
patients had an unstable cardiac status and had a long intubation time peri-operatively. This
article was Level 1 Evidence because it was a systematic review of randomized controlled trials
(Melnyk & Fineout-Overholt, 2011).
Since my PICO question addressed the issue of whether an IS was effective in preventing
post-operative complication in patients who were undergoing physical and/or occupational
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therapy (PT/OT) as opposed to those who were not, I will focus on this part of the article. The
reviewers looked at patients who were obtaining early ambulation, coughing and deep breathing
and early bed mobility; all of which are orchestrated through the assigned PT/OT therapist. They
also compared the use of the IS to physical therapy alone. The results state that there was not a
significant amount of reduction in PPCs with any of the interventions analyzed. The studies
indicate that using the IS in addition to or only using the IS showed no change in the outcome of
the patient (2013). They came to this conclusion by measuring vital capacity, forced expiratory
volume, arterial oxygenation, and cases of pneumonia or atelectasis.
Article Two
Incentive Spirometry: 2011 published in the Journal of Respiratory Care was written by
four authors who searched CINAHL, MEDLINE, and Cochrane library databases for all articles
pertaining to the use of an incentive spirometer (Restrepo, Tracy, Wettstien, & Wittnebel, 2011).
They looked between the years of 1995 and 2011 and found fifty-four clinical trials and
systematic reviews on the topic. After reviewing all the research and analyzing the results, they
made recommendations based on their findings. Before drawing conclusions, the authors took
into account the dependence of the IS’s effectiveness on patient cooperation, proper education,
and trained supervision during use. They also realized that the inability to guarantee these
elements affects the outcome of the trials.
The patients used in these trials ranged from being in acute-care settings to home care.
The authors included patients that were post-operative as well as those who had neuromuscular
diseases, low inspiratory capacity, spinal chord injuries and lung disorders (Restrepo et al, 2011).
The trials excluded patients who they felt would be unable to appropriately use the IS as
instructed, those who were very young or very old, sedated, or confused (2011). After reviewing
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all the data, the authors concluded several things. First, incentive spirometry is ineffective in
preventing PPCs alone. Second, it is recommended in conjunction with deep breathing exercises,
physical and occupational therapy, etc. Third, the use of an IS post-operatively to prevent
atelectasis is not recommended. This article concludes that and IS in ineffective in changing a
post-operative patient’s outcome for the better.
Article Three
The article, Incentive Spirometry for Prevention of Post-operative Pulmonary
Complications in Upper Abdominal Surgery, was published in the Cochrane Library this year. It
is a systematic review of articles found in the Cochrane Central Register of Controlled Trials,
MEDLINE, EMBASE, and LILACS up to 2013. The objective was to find out if the IS was
useful in preventing post-operative pulmonary complications used solo or with various therapies.
It included patients that were admitted for some type of upper abdominal surgery. Two unbiased
authors reviewed the data and compiled data. This article is Level 1 Evidence because it is a
methodical review of randomized controlled trials (Melnyk & Fineout-Overholt, 2011).
The authors started off including twelve studies that totaled 1834 patients. However, after
further review there were problems with the studies that included poor reporting, the use of bias
was unclear, or the patients seemed to be incompliant with the use of their incentive spirometer.
The part of the study that addresses my PICO question and answers whether the use of IS, in
adjunct to their therapy, improves patient’s pulmonary outcomes consisted of four trials (152
patients) (Nascimento et al, 2014). They compared IS to therapy, deep breathing and coughing,
chest physiotherapy and found that the use of an incentive spirometer did not change the chances
of the patient obtaining pulmonary complications. The study concludes that using IS is
ineffective in the prevention of PCCs by itself or in addition to other therapies (2014).
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Significance
Understanding the importance of evidence-based practice is what prompted my PICO
question. After reviewing the research surrounding the use of an incentive spirometer to help
prevent post-operative pulmonary complications, the conclusion was that the IS is ineffective or
unnecessary to prevent PPCs. As stated above, the prescribed use of an incentive spirometer can
prove to be frustrating for both the patient and nurse. It is because of my daily struggle with my
own patients that this topic was of great interest to me. The conclusion drawn from this research
impacts healthcare by increasing patient satisfaction, saving the medical facilities money, and
decreasing the stress and work for nurses. According to the American Nurses Association, it is
imperative for nurses to expand our body of knowledge and grow the profession by scholarly
inquiry (ANA, 2014). Then, it is our responsibility to take the information we have learned and
be an advocate for policy change.
Research and Nursing Practice
Over the years, research and its findings have influenced nursing practice, changed
policies and procedures and improved patient outcomes. By conducting research, we know that
central lines need to be flushed with normal saline and heparin every shift. We also know that it
is imperative to aspirate when giving an intramuscular injection. Additionally, we recognize that
a peripheral intravenous line needs a location change every three days and mouths need to be
rinsed after a steroid medication. Research is essential in forming a strong evidence-based
nursing practice (EBP) (Nieswiadomy, 2012, p. 267). However, without implementing what we
discover through research our nursing practice will not change.
In the past, nurses practiced what they were taught and most actions were based off of
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nursing traditions. Now, with the easy accessibility of research and the change from traditionbased nursing to evidence-based nursing, nurses are even more responsible for their actions. All
responses to a situation must be clearly justified. As nurses, it is our job to continually bring
nursing practice and nursing research together (Niesweiadomy, 2012, p. 267). Nurses are
responsible for the quality of care a patient receives and for the actions they perform. If there is
research that gives insight into a nursing practice, then the nurse should question that action and
bring the knowledge to the supervisor. It is up to us to advocate for policy and procedure changes
based on new research.
Realizing the importance of evidence-based practice integration into our nursing care, the
Quality and Safety Education for Nurses (QSEN) has a non-profit organization called The
Critical Appraisal Skills Program. This organization trains nurses in how to critically appraise
research and better understand it (QSEN, 2014). They give you the tools needed to correctly
analyze an article. For example, when reading a randomized control trial, like the ones reviewed
above, the QSEN’s program has checklists that you can use when going through the article, thus
making sure that it is scholarly, scientific, and relevant to nursing. It is important that we utilize
these tools, growing our evidence-based practice and creating positive patient outcomes.
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References
American Nurses Association (ANA) (2014). Code of ethics for nurses with interpretive
statements. Code of Ethics. Retrieved from
https://owl.english.purdue.edu/owl/resource/560/10/
angelsr28. (2010, April 26). Getting patients to use their incentive spirometer [Web log post].
Retrieved from http://allnurses.com/general-nursing-discussion/getting-patients-use475931.html
Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and
healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.
Nascimento, P., Norma, S.P., Módolo, S. A., Michele, M.F., Guimarães, L., Regina E.D. (2013)
Incentive spirometry for prevention of postoperative pulmonary complications in upper
abdominal surgery. Cochrane Anesthesia Group. doi:
10.1002/14651858.CD006058.pub3
Nieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Boston: Pearson.
onetiredmomma. (2010, April 26). Re: getting patients to use their incentive spirometer [Web log
comment]. Retrieved from http://allnurses.com/general-nursing-discussion/gettingpatients-use-475931.html
QSEN Institute (2014). EBP clinical appraisal tools. Evidenced Based Practice. Retrieved from
http://qsen.org/evidence-based-practice/
Restrepo, R., Tracy, M., Wettstein, R., Wittnebel, L. (2011). Incentive spirometry. Respiratory
Care 56(10). doi: http://0-dx.doi.org.libcat.ferris.edu/10.4187/respcare.01471
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Stannard, D. (2013). Incentive spirometry for preventing pulmonary complications after
coronary artery bypass graft. Journal of PeriAnesthesia Nursing. 28(4). doi:
10.1016/j.jopan.2013.05.003ifo
Ursuy, P. (2014). Nurs 350 syllabus summer [class handout]. School of Nursing, Ferris State
University, Big Rapids, MI.
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