Effectiveness of incentive spirometry in patients following thoracotomy and lung resection including those at high risk for developing pulmonary complications

Abstract

Background Following thoracotomy, patients frequently receive routine respiratory physiotherapy which may include incentive spirometry, a breathing technique characterised by deep breathing performed through a device offering visual feedback. This type of physiotherapy is recommended and considered important in the care of thoracic surgery patients, but high quality evidence for specific interventions such as incentive spirometry remains lacking. Methods 180 patients undergoing thoracotomy and lung resection participated in a prospective single-blind randomised controlled trial. All patients received postoperative breathing exercises, airway clearance and early mobilisation; the control group performed thoracic expansion exercises and the intervention group performed incentive spirometry.Results No difference was observed between the intervention and control groups in the mean drop in forced expiratory volume in 1 s on postoperative day 4 (40% vs 41%, 95% CI −5.3% to 4.2%, p=0.817), the frequency of postoperative pulmonary complications (PPC) (12.5% vs 15%, 95% CI −7.9% to 12.9%, p=0.803) or in any other secondary outcome measure. A high-risk subgroup (defined by ≥2 independent risk factors; age ≥75 years, American Society of Anaesthesiologists score ≥3, chronic obstructive pulmonary disease (COPD), smoking status, body mass index ≥30) also demonstrated no difference in outcomes, although a larger difference in the frequency of PPC was observed (14% vs 23%) with 95% CIs indicating possible benefit of intervention (−7.4% to 2.6%). Conclusions Incentive spirometry did not improve overall recovery of lung function, frequency of PPC or length of stay. For patients at higher risk for the development of PPC, in particular those with COPD or current/recent ex-smokers, there were larger observed actual differences in the frequency of PPC in favour of the intervention, indicating that investigations regarding the physiotherapy management of these patients need to be developed further. BACKGROUND

The Scientific Basis for Postoperative Respiratory Care

“…[31][32][33]35,37,40 Studies comparing incentive spirometry for PPC prevention after cardiac/thoracic surgery also include a trial with no intervention as the control, 48 and studies that compared incentive spirometry to other techniques. 44,45,47,48,51,52,54,55,58,60 The majority of these trials reported no difference between incentive spirometry and the comparator. 44,47,48,51,52,54,58,60 This creates one of the challenges in evaluating the evidence on incentive spirometry in PPC prevention.…”

“…44,45,47,48,51,52,54,55,58,60 The majority of these trials reported no difference between incentive spirometry and the comparator. 44,47,48,51,52,54,58,60 This creates one of the challenges in evaluating the evidence on incentive spirometry in PPC prevention. A randomized controlled trial with sufficient numbers should compare any of the techniques to a standard regimen of up and out of bed and early ambulation.…”

“…Similar findings were seen in studies evaluating the impact on postoperative lung volumes; that is, the most common finding was no difference between incentive spirometry and the other intervention or no intervention. 44,47,51,59,60 A recent paper by Agostini and colleagues compared incentive spirometry to "thoracic expansion exercises" in 180 patients following lung resection. 60 All patients received postoperative breathing exercises, airway clearance, and early mobilization.…”

“…44,47,51,59,60 A recent paper by Agostini and colleagues compared incentive spirometry to "thoracic expansion exercises" in 180 patients following lung resection. 60 All patients received postoperative breathing exercises, airway clearance, and early mobilization. There was no difference between the groups with respect to the fall in FEV 1 on postoperative day 4 or the frequency of PPCs.…”

“…Two main areas of investigation have been pursued: incentive spirometry for PPC prevention following upper abdominal surgery, [30][31][32][33][34][35][36][37][38][39][40][41][42][43] and incentive spirometry for PPC prevention following cardiac/thoracic surgery. [44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60] Comparison of these studies is difficult, owing to the various study designs (randomized controlled trials and prospective trials), the comparators (none, chest physical therapy [CPT], CPAP, expiratory airway pressure), the frequency of interventions (eg, hourly, every 4 hours), the duration of each intervention (number of maneuvers, minutes of therapy), and the outcomes (radiographic atelectasis, gas exchange, pneumonia, pulmonary function). Of the studies that used PPCs as an outcome, 3 compared incentive spirometry with a control group of no intervention following upper abdominal surgery.…”