Incentive Spirometry After Cardiothoracic Surgery
Incentive spirometry should NOT be used as a standalone intervention after cardiothoracic surgery, but may be added to a multimodal physiotherapy program that includes early mobilization, breathing exercises, and coughing techniques. 1
Core Recommendation
The evidence is clear that multimodal physiotherapy is superior to isolated incentive spirometry after cardiothoracic surgery. The most recent and highest-quality guidelines from 2021 demonstrate that adding incentive spirometry to comprehensive physiotherapy programs provides no additional benefit in reducing pulmonary complications or hospital length of stay 1.
What Works: Multimodal Physiotherapy Protocol
Your postoperative protocol should include at minimum:
- Early mobilization and walking (starting postoperative day 1)
- Breathing exercises (thoracic expansion exercises)
- Bronchial drainage and coughing techniques (supported coughing)
- Pain management education as an integral component
This combination reduces pulmonary complications from 15.5% to 4.7% (p < 0.001) when supervised by trained physiotherapists 1.
When to Consider Adding Incentive Spirometry
Incentive spirometry may be considered on a case-by-case basis as an adjunct to the above multimodal program, but should never replace it 1. The 2023 Canadian guidelines note that data on incentive spirometry effectiveness after cardiac surgery are "inconsistent" 2.
Evidence Analysis
Key negative findings:
- A 2026 randomized controlled trial found no additional benefit when incentive spirometry was added to cardiac rehabilitation versus cardiac rehabilitation alone—no differences in pulmonary complications, hospital stay, or functional recovery 3
- Agostini et al. (180 patients) found adding incentive spirometry to standard physiotherapy had no effect on complication rates or hospital length of stay 1
Conflicting evidence:
- Some older studies suggest preoperative incentive spirometry (2 days before surgery) may reduce atelectasis rates (20% vs 42.5%, p=0.03) and hospital stay 4
- Nurse-guided incentive spirometry protocols showed benefits in one 2022 study, but this compared against no intervention rather than multimodal physiotherapy 5
Critical Pitfall to Avoid
Do not order incentive spirometry alone. Historical controls using only nurse-supervised incentive spirometry had significantly worse outcomes (15.5% complication rate) compared to intensive multimodal physiotherapy (4.7% complication rate) 1. This represents the most clinically significant finding in the literature.
Practical Implementation
Postoperative physiotherapy protocol:
Day of surgery/POD 0: Remove unnecessary lines (chest drains, urinary catheters, central lines) as soon as safe to facilitate mobilization 6
POD 1-5: Twice-daily supervised sessions including:
- Assisted ambulation (progressive distance)
- Deep breathing exercises (10 breaths per session)
- Supported coughing with incision splinting
- Pain assessment and optimization before each session
Optional addition: Volume-oriented incentive spirometry (10 breaths per hour while awake) if resources permit and patient can perform correctly
Target: Patients should achieve mobilization out of bed by POD 1 and ambulate in hallways by POD 2 6
Special Considerations
For patients developing postoperative respiratory complications (hypoxemia, respiratory distress), escalate to non-invasive ventilation or high-flow oxygen rather than relying on incentive spirometry 1.
The evidence strongly supports physiotherapist supervision over nurse-supervised programs for optimal outcomes 1, though nurse-guided protocols with proper training may be acceptable when physiotherapy resources are limited 5.