The Generalist: Incentive Spirometry

The Generalist: Incentive Spirometry

Jake Anderson, DO, and Vanessa Cardy, MD

A recent Things We Do For No Reason^TM 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?

Background

• 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
  • No published data
• COVID-19 or recovery in long COVID
  • No published data
• 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
  • No benefit

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. 

REFERENCES:

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