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Reprinted from the December 1991 issue of RESPIRATORY CARE [Respir Care 1991;36(12):1402–1405]

AARC Clinical Practice Guideline

Incentive Spirometry

IS 1.0 PROCEDURE:

Incentive spirometry, also referred to as sustained maximal inspiration (SMI), is a component of bronchial hygiene therapy.(1-3)

IS 2.0 DESCRIPTION/DEFINITION:

2.1 Incentive spirometry is designed to mimic natural sighing or yawning by encouraging the patient to take long, slow, deep breaths.(1,2,4,5) This is accomplished by using a device that provides patients with visual or other positive feedback when they inhale at a predetermined flowrate or volume and sustain the inflation for a minimum of 3 seconds.(2,3,5-7)
The objectives of this procedure are to increase transpulmonary pressure and inspiratory volumes, improve inspiratory muscle perfor-mance,8 and re-establish or simulate the normal pattern of pulmonary hyperinflation.3 When the procedure is repeated on a regular basis, airway patency may be maintained and lung atelectasis prevented and reversed.(1-3,5,6,9,10)
2.2 Incentive spirometry should be contrasted with expiratory maneuvers (such as the use of blow bottles) that do not mimic the sigh and have been associated with the production of reduced lung volumes.(5,6)

IS 3.0 SETTINGS:

3.1 Critical care
3.2 Acute care inpatient
3.3 Extended care and skilled nursing facility
3.4 Home care(8)

IS 4.0 INDICATIONS:

4.1 Presence of conditions predisposing to the development of pulmonary atelectasis
4.1.1 upper-abdominal surgery(2,4,9-14)
4.1.2 thoracic surgery(9,10,13-15)
4.1.3 surgery in patients with chronic obstructive pulmonary disease (COPD)(7,13-15)
4.2 Presence of pulmonary atelectasis(16)
4.3 Presence of a restrictive lung defect associated with quadraplegia and/or dysfunctional diaphragm.(6,8,14,17,18)

IS 5.0 CONTRAINDICATIONS:

5.1 Patient cannot be instructed or supervised to assure appropriate use of the device.
5.2 Patient cooperation is absent(2,16) or patient is unable to understand or demonstrate proper use of the device.(16)
5.3 IS is contraindicated in patients unable to deep breathe effectively (eg, with vital capacity [VC] less than about 10 mL/kg or inspiratory capacity [IC] less than about one third of predicted).
5.4 The presence of an open tracheal stoma is not a contraindication but requires adaptation of the spirometer.

IS 6.0 HAZARDS AND COMPLICATIONS:

6.1 Ineffective unless closely supervised or performed as ordered(6)
6.2 Inappropriate as sole treatment for major lung collapse or consolidation
6.3 Hyperventilation
6.4 Barotrauma (emphysematous lungs)(19)
6.5 Discomfort secondary to inadequate pain control(15,18)
6.6 Hypoxia secondary to interruption of prescribed oxygen therapy if face mask or shield is being used
6.7 Exacerbation of bronchospasm
6.8 Fatigue(20,21)

IS 7.0 LIMITATIONS OF METHOD:

Evidence suggests that deep breathing alone without mechanical aides can be as beneficial as incentive spirometry in preventing or reversing pulmonary complications,(1-5) and controversy exists concerning overuse of the procedure.(1,4,6)

IS 8.0 ASSESSMENT OF NEED:

8.1 Surgical procedure involving upper abdomen or thorax(4,5)
8.2 Conditions predisposing to development of atelectasis including immobility, poor pain control, and abdominal binders
8.3 Presence of neuromuscular disease involving respiratory musculature(8)

IS 9.0 ASSESSMENT OF OUTCOME:

9.1 Absence of or improvement in signs of atelectasis
9.1.1 decreased respiratory rate(16,17)
9.1.2 resolution of fever(2,18)
9.1.3 normal pulse rate(14)
9.1.4 absent crackles (rales)(20) or presence of or improvement in previously absent or diminished breath sounds
9.1.5 normal chest x-ray(2)
9.1.6 improved arterial oxygen tension (PaO2) and decreased alveolar-arterial oxygen tension gradient, or P(A-a)O2(1,3,4,9,10)
9.1.7 increased VC and peak expiratory flows(4,16,17)
9.1.8 return of functional residual capacity (FRC) or VC to preoperative values4,(15-17) in absence of lung resection
9.2 Improved inspiratory muscle perfor-mance
9.2.1 attainment of preoperative flow and volume levels1(1)
9.2.2 increased forced vital capacity (FVC)

IS 10.0 RESOURCES:

10.1Equipment
10.1.1 incentive spirometer
10.1.2 conclusive evidence to support the use of one type or brand of device over others is lacking(20,22)
10.2 Personnel
10.2.1 Level I personnel should possess
10.2.1.1 mastery of techniques for proper operation and clinical application of device(6) and understanding of the importance of effective postopera-tive pain relief(15,16,18) and the absence of other impediments to patient cooperation (such as residual anesthetic or sensory impairment(12,17))
10.2.1.2 ability to instruct patient in proper technique(2,6) and an under-standing of the importance of preoperative instruction and supervised practice
10.2.1.3 ability to respond appropriately to adverse effects
10.2.1.4 knowledge of and ability to implement Universal Precautions
10.2.2 Level II personnel, in addition to possessing knowledge and abilities described in 10.2.1.1-10.2.1.4, should have demonstrated ability to assess patient need for and response to therapy and recommend modifications and discontinu-ance as appropriate.

IS 11.0 MONITORING:

Direct supervision of every patient performance is not necessary once the patient has demonstrated mastery of technique;(6,16,23) however, preoperative instruction, volume goals, and feedback are essential to optimal performance.
11.1 Observation of patient performance and utilization
11.1.1 frequency of sessions(16)
11.1.2 number of breaths/session(16)
11.1.3 inspiratory volume or flow goals achieved(16) and 3- to 5-second breath-hold maintained
11.1.4 effort/motivation(16)
11.2 Periodic observation of patient compliance with technique,(6,16,23) with additional in-struction as necessary
11.3 Device within reach of patient(5) and patient encouraged to perform independently
11.4 New and increasing inspiratory volumes established each day
11.5 Vital signs

IS 12.0 FREQUENCY:

A number of authors suggest using the device 5-10 breaths per session, at a minimum, every hour while awake (ie, 100 times a day).(2,7,19) Caregiver does not need to be present with each performance, and patient should be encouraged to perform independently.

IS 13.0 INFECTION CONTROL:

13.1 Universal Precautions(24)
13.2 Proper labeling and appropriate storage of devices between uses and appropriate cleaning of devices between patients(25)
Bronchial Hygiene Guidelines Committee:

Lana Hilling RCP CRTT, Chairman, Concord CA
Eric Bakow RRT, Pittsburg PA
Jim Fink RCP RRT, San Francisco CA
Chris Kelly BS RRT, Oakland CA
Dennis Sobush MA PT, Milwaukee WI
Peter A Southorn MD, Rochester MN

REFERENCES
  1. Bartlett RH Krop P, Hanson EL, Moore FD. Physiology of yawning and its application to postoperative care. Surg Forum 1970;21:223-224.
  2. Craven JL, Evans GA, Davenport PJ, Williams RHP. The evaluation of incentive spirometry in the management of postoperative pulmonary complications. Br J Surg 1974;61:793-797.
  3. Darin J. Effectiveness of hyperinflation therapies for the prevention and treatment of postoperative atelectasis. Curr Rev Respir Ther 1984;12:91-95.
  4. Meyers JR, Lembeck L, O'Kane H, Baue AE. Changes in residual capacity of the lung after operation. Arch Surg 1975;110:567-583.
  5. Petz TJ. Physiologic effects of IPPB, blow bottles and incentive spirometry. Curr Rev Respir Ther 1979;1:107-111.
  6. Scuderi J, Olsen GN. Respiratory therapy in the management of postoperative complications. Respir Care 1989;34:281-291.
  7. Dohi S, Gold MI. Comparison of two methods of postoperative respiratory care. Chest 1978;73:592-595.
  8. Walker J, Cooney M, Norton S. Improved pulmonary function in chronic quadriplegics after pulmonary therapy and arm ergometry. Paraplegia 1989;27:278-283.
  9. Iverson LIG, Ecker RR, Fox HE, May IA. A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Ann Thorac Surg 1978; 35:197-200.
  10. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complication after abdominal surgery. Am Rev Respir Dis 1984;130:12-15.
  11. Jung R, Wright J, Nusser R, Rosoff L. Comparison of three methods of respiratory care following upper abdominal surgery. Chest 1980;78:31-35.
  12. Lyager S, Wernberg M, Ragani N, Boggold-Madsen B, Nelsen B, Nelsen HC, et al. Can postoperative pulmonary conditions be improved by treatment with the Bartlett-Edwards incentive spirometer after upper abdominal surgery? Acta Anaesth 1979;23:312-319.
  13. Indihar FJ, Forsberg DP, Adams AB. A prospective comparison of three procedures used in attempts to prevent postoperative pulmonary complications. Respir Care 1982;27:564-568.
  14. Anderson WH, Dossett BE, Hamilton GL. Prevention of postoperative pulmonary complications. JAMA 1963;186:103-106.
  15. Sabaratnam S, Eng J, Mearns AJ. Alterations in respiratory mechanics following thoracotomy. J R Coll Surg Edinb 1990;35:144-150.
  16. Bartlett RH. Respiratory therapy to prevent pulmonary complications of surgery. Respir Care 1984;29:667-679.
  17. Stock MC, Downs JB, Gauer PK, Alster JM, Imrey PB. Prevention of postoperative pulmonary complications with CPAP, incentive spirometry, and conservative therapy. Chest 1985;87:151-157.
  18. Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham H. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax 1989;44:634-639.
  19. Colgan FJ, Mahoney PD, Fanning GL. Resistance breathing (blow bottles) and sustained hyperinflations in the treatment of atelectasis. Anesthesiology 1970;32:543-550.
  20. Mang H, Obermayer A. Imposed work of breathing during sustained maximal inspiration: comparison of six incentive spirometers. Respir Care 1989; 34:1122-1128.
  21. Jones FL. Increasing postoperative ventilation: a comparison of five methods. Anesthesiology 1962; 29:1212-1214.
  22. Lederer DH, Vandewater JM, Indech RB. Which breathing device should the preoperative patient use? Chest 1980;77:610-613.
  23. Rau JL, Thomas L, Haynes RL. The effect of method of administering incentive spirometry on postoperative pulmonary complications in coronary artery bypass patients. Respir Care 1988;33:771-778.
  24. Centers for Disease Control. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings. MMWR 1988;37:377-388.
  25. Boyce JM, White RL, Spruill EY, Wall M. Cost-effective application of the Centers for Disease Control guidelines for prevention of nosocomial pneumonia. Am J Infect Control 1985;3:228-232.
ADDITIONAL BIBLIOGRAPHY

Bartlett RH, Gazzaniga AB, Geraghty TR. Respiratory maneuvers to prevent postoperative pulmonary complications. JAMA 1973;224:1017-1021.

Bartlett RH, Brennan ML, Gazzaniga AB, Hanson EL. Studies on the pathogenesis and prevention of postoperative pulmonary complications. Surg 1988;137:925-933.

Comroe JH, Forster RF, DuBois AB, Briscoe WA, Carlsen E. The lung, 2nd ed. Chicago: Year Book Medical Publishers Inc, 1968:176-178.

Ford GT, Guenter CA. Toward prevention of postoperative pulmonary complications. Am Rev Respir Dis 1984;130:4-5.

Marini JJ. Postoperative atelectasis: pathophysiology, clinical importance, and principles of management. Respir Care 1984;29:516-528.

O'Connor M, Tattersoll MP, Carter JA. An evaluation of the incentive spirometer to improve lung function after cholecystectomy. Anaesthesia 1988;43:785-787.

Paul WL, Downes JB. Postoperative atelectasis. Arch Surg 1981;116:861-863.

Roukema JA, Carol EJ, Prins JG. Prevention of pulmonary complications after upper abdominal surgery in patients with noncompromised pulmonary status. Arch Surg 1988;123:30-34.

VanDeWater JM, Watring WC, Linton LA, Murphy M, Byron RL. Prevention of postoperative pulmonary complications. Surg Gynecol Obstet 1972;135:229-233.

Marini JJ, Baker WL, Lamb VJ. Breath stacking increases the depth and duration of chest expansion by incentive spirometry. Am Rev Respir Dis 1990;141:343-346.

Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.

Reprinted from the December 1991 issue of RESPIRATORY CARE [Respir Care 1991;36(12):1402–1405]

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