What is the ideal protocol for incentive spirometry (IS) in postoperative abdominal surgery?

Incentive Spirometry Protocol in Postoperative Abdominal Surgery

Primary Recommendation

Use incentive spirometry as part of a multimodal respiratory care program, not as a standalone intervention, with patients performing 10 maximal inspiratory maneuvers hourly while awake for at least 2-4 weeks postoperatively. 1

Evidence Summary

The evidence demonstrates that incentive spirometry (IS) alone is not superior to other lung expansion techniques, but any lung expansion intervention is better than no prophylaxis at all. 2 The most recent guidelines emphasize that IS should be integrated into comprehensive pulmonary care rather than used in isolation. 2, 1

Specific Protocol Components

Patient Selection

• High-risk patients who benefit most from IS include: 2

  • Those undergoing abdominal, thoracic, head, or neck operations 2
  • Patients with chronic obstructive pulmonary disease 2
  • Those with musculoskeletal abnormalities of the chest 2
  • Patients with abnormal pulmonary function tests 2
  • Age >60-75 years 2, 3
  • ASA class II or higher 2

• Low-risk patients (ASA class 1-2 undergoing routine procedures) show no significant benefit from IS alone 4

Technique and Frequency

• Position: Sit upright when using the incentive spirometer for optimal lung expansion 1
• Breathing technique: Take a slow, deep breath through the mouthpiece, hold for 3-5 seconds, then exhale 1
• Frequency: Perform 10 maximal inspiratory maneuvers every hour while awake 1, 5
• Duration: Continue for at least 2-4 weeks postoperatively to prevent respiratory complications 1

Integration with Multimodal Care

Critical caveat: Recent high-quality evidence shows no benefit for IS when added to comprehensive physiotherapy programs. 2 Therefore, IS should be part of—not in addition to—the following interventions:

Essential Components to Combine with IS:

• Early mobilization: Patients should be out of bed on the day of surgery 2, 3
• Deep breathing exercises: Perform 10 times every hour while awake 1
• Supported coughing: Use pillow splinting across the abdomen when coughing 2, 1
• Adequate pain control: Essential to allow effective deep breathing 2, 3
  • Epidural analgesia preferred for upper abdominal surgery 2
  • Systemic analgesia with minimal cough-suppressant effect 2
  • Regional analgesia techniques 2

Alternative Approaches When IS Cannot Be Performed

If patients are unable to perform IS or deep breathing exercises effectively:

• CPAP or NIPPV at 8-10 cm H₂O for at least 8-12 hours following extubation is superior to standard oxygen therapy for hypoxemic patients 2, 3
• This requires staff competent in these therapies and continuous physiological monitoring 2

What Does NOT Work

Important limitations from recent evidence:

• IS alone shows no superiority over deep breathing exercises or chest physiotherapy 2, 5, 6
• Adding IS to comprehensive physiotherapy programs provides no additional benefit 2
• IS has no benefit in low-risk patients 4
• Combined methods (IS plus other techniques) do not provide additional risk reduction beyond single modalities 2

Practical Implementation Algorithm

1. Preoperatively: Instruct high-risk patients on IS technique, deep breathing, and coughing 2
2. Immediately postoperatively: Begin IS hourly while awake, combined with early mobilization 2, 1
3. Ongoing: Ensure adequate pain control to facilitate compliance 2, 3
4. If hypoxemic (SpO₂ <90%): Escalate to CPAP/NIPPV rather than relying solely on IS 2, 3
5. Continue: Maintain IS and mobilization for 2-4 weeks 1

Common Pitfalls to Avoid

• Do not use IS as the sole intervention—it must be part of multimodal care 2, 1
• Do not apply to low-risk patients—focus resources on high-risk populations 4
• Do not neglect pain control—inadequate analgesia prevents effective IS use 2, 3
• Do not delay mobilization—early ambulation is equally or more important than IS 2, 3
• Do not continue standard oxygen therapy alone if patient remains hypoxemic—escalate to CPAP/NIPPV 2, 3