What is the recommended usage and protocol for an incentive spirometer (IS) in patients with respiratory conditions?

Incentive Spirometry: Clinical Protocol and Usage Guidelines

Incentive spirometry should be used as part of a comprehensive pulmonary care program—not in isolation—with patients performing 10 breaths, 3-5 times daily, holding each inspiration for 3-5 seconds, while sitting upright to optimize lung expansion. 1, 2

Patient Selection and Contraindications

Appropriate Candidates

• Patients with rib fractures (particularly ≥3 displaced fractures) who are at high risk for atelectasis and pneumonia 2
• Post-surgical patients requiring prevention of pulmonary complications 3
• Flail chest patients as part of respiratory care protocols 2

Absolute Contraindications

• Large bullae (>1/3 hemithorax) in COPD patients, as forced inspiratory maneuvers can rupture bullae causing pneumothorax 1
• Altered mental status or inability to follow instructions, since the device requires voluntary cooperation and adequate inspiratory effort 1
• Active hemoptysis due to risk of worsening bleeding with forced respiratory maneuvers 1

High-Risk Populations Requiring Special Monitoring

• Pulmonary arterial hypertension patients are at critical risk for hypotension during respiratory maneuvers due to disruption of the SVR/PVR balance; deep inspiratory maneuvers can acutely decrease right ventricular preload and increase afterload, potentially triggering sudden cardiovascular collapse 1
• Hemodynamically unstable patients requiring vasopressor support or with borderline blood pressure 1
• Right heart failure patients who may experience reduced venous return and cardiac output during sustained inspiratory effort 1

Proper Technique and Protocol

Patient Positioning

• Sit upright when using the incentive spirometer for optimal lung expansion 2
• Testing should preferably be done in a sitting position using a chair with arms and without wheels 4

Step-by-Step Technique

• Take a slow, deep breath through the mouthpiece 2
• Hold the breath for 3-5 seconds at maximum inspiration 2
• Exhale slowly and completely 2
• Perform 10 breaths per session 3, 5
• Repeat 3-5 times daily for optimal benefit 2, 3

Duration of Therapy

• Continue for at least 2-4 weeks to prevent respiratory complications 2
• In outpatient settings, a 30-day regimen can produce a 16% increase in maximal inspiratory volume 3

Essential Precautions and Monitoring

Pre-Initiation Screening

• Screen for pulmonary hypertension, right heart failure, baseline hypotension, and vasopressor requirement before starting incentive spirometry 1
• Ensure adequate pain control before initiating therapy, particularly in patients with rib fractures, as pain significantly impairs effectiveness 1, 2

Hemodynamic Monitoring for High-Risk Patients

• Continuous blood pressure monitoring before, during, and after initial sessions in at-risk patients 1
• Arterial line monitoring may be appropriate in ICU settings with pulmonary hypertension patients 1
• Instruct patients to stop immediately if experiencing lightheadedness or dizziness 1

Alternative Therapies for High-Risk Patients

• Patients with known pulmonary hypertension should be considered for alternative respiratory therapies rather than aggressive incentive spirometry 1
• Avoid aggressive incentive spirometry targets in hemodynamically vulnerable patients 1

Integration with Comprehensive Care

Multimodal Approach

• Never use incentive spirometry in isolation; it must be part of comprehensive pulmonary care 1, 2
• Combine with early mobilization and walking 2
• Integrate deep breathing exercises and supported coughing techniques (splinting the injured area) 2
• Ensure adequate pain control to allow effective deep breathing 2

Evidence of Effectiveness

• Multimodal physiotherapy programs including incentive spirometry reduced postoperative pulmonary complications from 15.5% to 4.7% compared to controls 2
• Intensive physiotherapy programs are more effective than isolated interventions 2

Special Populations

Preschool Children

• Incentive spirometry computer programs with interactive cartoon games may increase success in achieving maximal forced expiration 4
• Animations should encourage rapid AND prolonged expiration, not just rapid expiration alone, as flow-driven incentives used in isolation lead to underestimation of FVC 4
• Incentives encouraging tidal breathing and maximal inspiration may also be helpful 4

Chest Trauma Patients

• Regional anesthesia techniques may facilitate better use of incentive spirometry in patients with severe pain 2
• Particularly beneficial for patients with multiple displaced rib fractures 2

Common Pitfalls to Avoid

• Do not rely on preoperative incentive spirometry alone to prevent postoperative lung function decline; evidence shows preoperative use does not lead to significant improvements 6
• Avoid prolonged exhalation times >15 seconds as they rarely change clinical decisions and may cause lightheadedness, syncope, undue fatigue, and unnecessary discomfort 4
• Do not use in patients with large bullae without careful risk assessment 1
• Never initiate without screening for pulmonary hypertension in at-risk populations 1

Patient Education and Compliance

• Hands-on instruction on proper device use and accurate measurement recording improves outcomes 3
• Use-tracking reminder devices (such as SpiroTimer™) have been shown to improve compliance, length of stay, and mortality 5
• Nurses report that reminder devices help both patients and providers, reducing the number of times staff must remind patients while improving patient engagement 5