The Generalist: Incentive Spirometry
Jake Anderson, DO, and Vanessa Cardy, MD
A recent Things We Do For No ReasonTM article dispelled the myth that routine use of postoperative incentive spirometry has any benefit in preventing pulmonary complications. But does incentive spirometry have value in other situations?
- Incentive spirometers are mechanical devices to help patients take long, deep, slow breaths in order to increase lung inflation.
- Their use is based on the theory that lung inflation improves atelectasis.
- Two separate Cochrane reviews (for abdominal surgery and coronary artery bypass surgery) showed a lack of benefit in preventing postoperative pulmonary complications.
Incentive spirometry in other scenarios:
- Rib fracture or chest wall trauma
- There is little data, but the best available evidence from a small randomized controlled trial (RCT) published in 2019 showed that the spirometry group had fewer complications, eg, delayed hemothorax, need for tube thoracostomy, atelectasis (number needed to treat [NNT] = 2).
- Acute respiratory illnesses, eg, pneumonia/chronic obstructive pulmonary disease (COPD) exacerbation
- COVID-19 or recovery in long COVID
- Chronic lung conditions, eg, COPD
- One very small RCT in patients with COPD showed improvement of health-related quality of life and blood gases in the spirometry group, but interpretation was limited by study size.
- Acute chest complications of sickle cell disease
- An old publication from the early 90s showed some improvement of chest X-ray appearance (not very patient oriented).
- Lung resection
So, in many cases, there is evidence of no benefit or no evidence of benefit. What are the harms?
- It doesn’t seem to put people at risk of lung injury or physical complications.
- The main harm is financial. A 2018 article showed the annual cost in the United States is over $1B.
- There is also an environmental cost of plastic devices with little evidence of clinical benefit.
PEARL: Ultimately, it’s probably better to focus on interventions that are known to be helpful instead of incentive spirometry, such as early mobilization.
Things We Do for No Reason™: Routine use of postoperative incentive spirometry to reduce postoperative pulmonary complications
Larsen T, Chuang K, Patel S, et al. J Hosp Med. 2022;17(12):1010-1013. doi: 10.1002/jhm.12898. PMID: 35972342
Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft
Freitas ERFS, Soares BGO, Cardoso JR, et al. Cochrane Database Syst Rev. 2012;2012(9):CD004466. doi:10.1002/14651858.CD004466.pub3. PMID: 22972072
Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery
do Nascimento Junior P, Módolo NSP, Andrade S, et al. Cochrane Database Syst Rev. 2014;2014(2):CD006058. doi: 10.1002/14651858.CD006058.pub3. PMID: 24510642
Jason M. - April 4, 2023 8:49 PM
Dr. Cardy at 8:23 you imply that “sucking in” is incorrect form. Have you ever used an incentive spirometer? That’s how it’s done. Slow inhale trying to maintain a velocity while reaching the prescribed goal volume, then hold 10 seconds, followed by breathing out. Perhaps you confuse it with PFTs…
Vanessa C. - April 9, 2023 6:48 PM
Thanks for writing in and helping me realize that the way I worded that phrase could certainly lead to confusion. When I said I saw patients sucking in on the incentive spirometer as opposed to blowing into it, I meant that I have seen folks take a deep breath in, with it in their mouth and then exhale after removing the spirometer from their mouth. As if it were an inhaler in a way. Will get an audio fix done soon to clarify that so there isn't confusion.
Thanks for listening