No, Do Not Use Incentive Spirometry in Active Pneumothorax
Incentive spirometry should be avoided in patients with an active pneumothorax, as it generates high intrathoracic pressures that can worsen the pneumothorax or delay resolution. This is particularly dangerous in patients with underlying lung disease.
Why Incentive Spirometry is Contraindicated
The physiologic mechanism is straightforward: incentive spirometry requires forceful inspiratory maneuvers that create large negative swings in intrathoracic pressure. This mechanical stress on lung tissue can:
- Expand the existing pneumothorax by increasing the pressure gradient between the pleural space and atmosphere
- Prevent lung re-expansion by maintaining air in the pleural cavity
- Potentially cause tension pneumothorax in symptomatic patients
A case report documented a secondary pneumothorax directly caused by aggressive incentive spirometer use in a patient with emphysema 1. The patient's repeated forceful inspiratory maneuvers in the setting of hyperinflated lungs led to mechanical stress and pneumothorax development.
What Activities to Avoid During Active Pneumothorax
The cystic fibrosis pulmonary guidelines explicitly recommend that patients should not perform spirometry for 2 weeks after pneumothorax resolution 2. If spirometry itself (which involves forced breathing maneuvers) should be avoided even after resolution, incentive spirometry during an active pneumothorax is clearly inappropriate.
Additional activities to avoid include:
- Positive expiratory pressure devices - should not be used with active pneumothorax 2
- Intrapulmonary percussive ventilation - contraindicated 2
- BiPAP/noninvasive ventilation - should be withheld as long as pneumothorax is present 2
- Weight lifting (>5 pounds) - avoid for 2 weeks after resolution 2
Appropriate Respiratory Management
Instead of incentive spirometry, focus on:
During Active Pneumothorax:
- High-flow oxygen (10 L/min) to accelerate pneumothorax reabsorption by increasing the pressure gradient between pleural capillaries and pleural cavity 3
- Exercise caution with oxygen in COPD patients who may be CO2 retainers 3
- Definitive treatment: needle aspiration, chest tube drainage, or conservative observation depending on size and symptoms 4, 5
After Pneumothorax Resolution:
- Wait at least 2 weeks before resuming any forced breathing exercises 2
- Deep breathing exercises without devices may be appropriate once cleared
- Gradual return to normal respiratory therapy as tolerated
Post-Thoracotomy Context
The one exception where incentive spirometry has been studied is after thoracotomy for pneumothorax treatment (not during active pneumothorax). One study showed that deep breathing exercises with or without an incentive spirometer were both effective for recovering pulmonary function after thoracotomy 6. However, this applies only after surgical resolution of the pneumothorax, not during the acute phase.
Clinical Pitfall to Avoid
Do not confuse post-operative respiratory therapy (after pneumothorax has been surgically treated) with management of an active pneumothorax. The former may include incentive spirometry as part of recovery; the latter absolutely should not.