Can Incentive Spirometry Be Used in Pneumothorax with Chest Drain In Situ?
Yes, incentive spirometry can be safely used in patients with pneumothorax who have an intercostal chest drain (ICD) in place, provided the drain is functioning properly and the patient is clinically stable.
Rationale and Clinical Approach
The available guidelines on pneumothorax management 1 do not specifically contraindicate incentive spirometry in patients with chest drains. In fact, the physiological principles support its use:
Key Safety Considerations
When incentive spirometry is appropriate:
- The chest drain must be functioning and connected to an underwater seal system
- The drain should NOT be clamped during incentive spirometry exercises 1
- Patient must be clinically stable without signs of tension pneumothorax
- No active, large air leak that would be exacerbated by increased inspiratory effort
Critical contraindication: A bubbling chest tube should never be clamped 1. If incentive spirometry is performed with an active air leak, the drain must remain open to the underwater seal to prevent tension pneumothorax.
Evidence Supporting Use
Research demonstrates that incentive spirometry can be beneficial in pneumothorax patients:
- Post-thoracotomy pneumothorax patients: Deep breathing exercises with incentive spirometry effectively improved pulmonary ventilatory function after thoracic surgery 2
- Primary spontaneous pneumothorax: A case report showed successful conservative management using incentive spirometry alone in a patient who refused chest tube insertion 3
- Physiological basis: Incentive spirometry promotes lung re-expansion through sustained maximal inspiration, which is mechanically appropriate when a functioning drainage system is in place 4
Practical Implementation
How to safely administer:
- Verify drain function: Ensure the chest drain is patent, properly positioned, and connected to underwater seal
- Check for air leak: Note if there is active bubbling through the drain
- Monitor during use: Observe the underwater seal chamber during incentive spirometry - some increased bubbling may occur but should not be excessive
- Patient positioning: Keep patient upright or semi-recumbent to optimize lung mechanics
- Frequency: Typically 10 breaths per hour while awake, adjusted based on patient tolerance
Warning signs to stop immediately:
- Development of sudden breathlessness
- Subcutaneous emphysema
- Chest pain
- Excessive air leak (continuous vigorous bubbling)
- Hemodynamic instability
Clinical Context
The BTS guidelines emphasize that pneumothorax management should focus on preventing complications and promoting lung re-expansion 1. Incentive spirometry aligns with these goals by:
- Preventing atelectasis in the re-expanding lung
- Maintaining respiratory muscle function during hospitalization
- Potentially accelerating lung re-expansion through controlled negative pressure generation
Special Populations
In cystic fibrosis patients with pneumothorax: The guidelines specifically note the importance of preventing sputum retention, which can delay lung re-expansion 1. Incentive spirometry may be particularly valuable in this population to maintain airway clearance while the chest drain is in place.
In secondary spontaneous pneumothorax: Patients with underlying lung disease benefit from maintaining pulmonary function during treatment. Recent evidence suggests incentive spirometry may reduce postoperative pulmonary complications in higher-risk patients with COPD 5.
Important Caveats
- Incentive spirometry should be supervised initially by experienced nursing or physiotherapy staff who understand chest drain management
- The intervention is adjunctive to standard care, not a replacement for appropriate drainage
- If the pneumothorax fails to resolve within 48 hours, referral to a respiratory physician is indicated regardless of adjunctive therapies 1
Bottom line: Incentive spirometry is safe and potentially beneficial in pneumothorax patients with functioning chest drains, as long as the drain remains open to underwater seal and the patient is monitored for complications. The practice aligns with physiological principles of lung re-expansion and has supporting evidence in thoracic surgery populations 2, 4.