Is incentive spirometry (IS) safe and effective for a Chronic Obstructive Pulmonary Disease (COPD) patient with bullae?

Incentive Spirometry in COPD Patients with Bullae

Incentive spirometry should NOT be used in COPD patients with bullae due to the significant risk of pneumothorax. 1

Risks of Incentive Spirometry in Bullous Emphysema

• Forceful inspiratory maneuvers with incentive spirometry can cause large negative swings in intrathoracic pressure, resulting in mechanical stress on lung tissue in patients with bullae 1
• There is documented evidence of secondary pneumothorax directly associated with aggressive use of incentive spirometry in a patient with emphysema 1
• The forceful inspiration required for incentive spirometry can potentially rupture bullae, leading to pneumothorax which increases morbidity and mortality 1

Alternative Approaches for COPD Patients with Bullae

Recommended Pharmacologic Therapy

• For stable COPD patients with respiratory symptoms and FEV1 <60% predicted, inhaled bronchodilators are recommended as first-line therapy 2
• Monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled β-agonists is recommended for symptomatic COPD patients with FEV1 <60% predicted 2
• Choice of specific monotherapy should be based on patient preference, cost, and adverse effect profile 2

Pulmonary Rehabilitation

• Pulmonary rehabilitation improves health status and dyspnea in patients with FEV1 <50% predicted 2
• For COPD patients with bullae, standard pulmonary rehabilitation without incentive spirometry is safer and still effective 3

Oxygen Therapy

• Supplemental oxygen reduces mortality rates among symptomatic patients with resting hypoxemia 2
• Long-term oxygen therapy shows a reduction in mortality for patients with severe resting hypoxemia (PaO2 ≤55 mm Hg) 2

Management Options for Bullae in COPD

For Patients with Giant Bullae

• Bullectomy may be considered for patients with giant bullae (occupying >1/3 of hemithorax) surrounded by relatively normal parenchyma 4
• Bronchoscopic lung volume reduction via endobronchial one-way valves is less invasive and has a lower mortality rate than lung volume reduction surgery for patients with bullae 5
• Combination of endobronchial valves and percutaneous catheter insertion might accelerate the release of large bullae and improve lung function 5

Lung Volume Reduction Surgery (LVRS)

• LVRS should be considered for patients with upper-lobe predominant emphysema and low exercise capacity 4
• Patients with homogeneous emphysema and good exercise capacity should not undergo LVRS due to higher mortality risk 4
• LVRS is contraindicated in patients with FEV1 ≤20% predicted with either homogeneous emphysema on HRCT or DLCO ≤20% predicted 4

Important Considerations for COPD Management

• Spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms but should not be used to screen for airflow obstruction in individuals without respiratory symptoms 2
• All current smokers should receive smoking cessation counseling and be offered pharmacologic therapies to increase cessation rates 2
• All patients 50 years of age or older should be offered influenza vaccine annually 2

Conclusion

While incentive spirometry has shown some benefit in general COPD rehabilitation 6, 7, the presence of bullae represents a significant contraindication due to the risk of pneumothorax 1. Alternative approaches including standard bronchodilator therapy, pulmonary rehabilitation without incentive spirometry, and consideration of surgical or bronchoscopic interventions for bullae management are more appropriate for these patients.