Incentive Spirometry Protocol for Preventing Pulmonary Complications
Direct Answer
All high-risk patients should perform incentive spirometry with 10 maximal inspiratory maneuvers every hour while awake (not every 2 hours) for at least 2-4 weeks postoperatively (not 10 days), as part of a multimodal respiratory care program that includes early mobilization and deep breathing exercises. 1
Patient Selection for Incentive Spirometry
High-risk patients who require this intervention include those with: 2
- Chronic obstructive pulmonary disease 2
- Age >60 years 2
- ASA class II or higher 2
- Functional dependence 2
- Congestive heart failure 2
- Low serum albumin (<35 g/L) 2
Procedure-related risk factors requiring intervention: 2
- Prolonged surgery (>3 hours) 2
- Abdominal, thoracic, neurosurgery, head and neck surgery, vascular surgery, or aortic aneurysm repair 2
- Emergency surgery 2
- General anesthesia 2
Correct Protocol and Frequency
The prescribed "every 2 hours" frequency is inadequate. The American Thoracic Society recommends performing 10 maximal inspiratory maneuvers every hour while awake, not every 2 hours. 1 This hourly frequency is critical for effectiveness.
The 10-day duration is also insufficient. Continue incentive spirometry for at least 2-4 weeks postoperatively to prevent respiratory complications. 3, 1
Proper Technique
- Sit upright when using the device for optimal lung expansion 3
- Take a slow, deep breath through the mouthpiece 3
- Hold the breath for 3-5 seconds before exhaling 3
- Perform this 10 times consecutively each hour 1
Critical Integration with Multimodal Care
A common pitfall is using incentive spirometry as an isolated intervention—this approach is ineffective. 1, 4 The American College of Physicians emphasizes that incentive spirometry must be combined with: 2
- Deep breathing exercises performed 10 times every hour while awake 3, 4
- Early mobilization beginning on the day of surgery, progressing from bed mobility to walking 4
- Supported coughing with splinting of the surgical site 4
- Adequate pain control to enable effective deep breathing 1, 4
The evidence shows that multimodal physiotherapy programs including incentive spirometry reduced postoperative pulmonary complications from 15.5% to 4.7% compared to controls. 3 However, incentive spirometry alone showed equivalent outcomes to standard chest physiotherapy in a large trial of 876 patients (15.8% vs 15.3% complication rates). 5
Evidence Quality and Nuances
The American College of Physicians guideline provides good evidence supporting incentive spirometry and deep breathing exercises as risk reduction strategies. 2 However, the literature reveals important nuances:
- A 2021 review found no general benefit in thoracic surgery patients, but emerging evidence shows benefit in higher-risk populations such as those with COPD. 6
- A 2007 study demonstrated that intensive postoperative physiotherapy programs including incentive spirometry decreased pulmonary complications from 17% to 6% (p=0.01). 7
- Patient adherence remains a significant challenge limiting effectiveness. 6
Selective Nasogastric Tube Use
As part of the comprehensive strategy, use nasogastric tubes selectively only for postoperative nausea/vomiting, inability to tolerate oral intake, or symptomatic abdominal distention—not routinely. 2 Routine nasogastric decompression increases pneumonia and atelectasis rates. 2
Alternative for Unable Patients
If patients cannot perform incentive spirometry or deep breathing exercises effectively, use CPAP or NIPPV at 8-10 cm H₂O for at least 8-12 hours following extubation for hypoxemic patients. 1
Warning Signs Requiring Immediate Attention
Patients should seek immediate medical care for: 3