What is the role and indication of incentive spirometry (IS) in patients at risk of pulmonary complications?

Incentive Spirometry: Comprehensive Overview

Direct Recommendation

Incentive spirometry should be used as part of multimodal pulmonary care—not as a standalone intervention—in high-risk surgical patients, though evidence shows it provides no advantage over deep breathing exercises alone and is inferior to positive pressure techniques. 1, 2, 3

Indications for Use

High-Risk Patient Populations

Incentive spirometry is indicated for patients with the following characteristics:

• Age >60 years (strongest patient-related risk factor) 2, 3
• ASA class II or greater 1, 2
• Chronic obstructive pulmonary disease 1, 2, 3
• Functionally dependent status 1, 2
• Congestive heart failure 1, 2
• Low serum albumin (<35 g/L), one of the most powerful predictors of postoperative pulmonary complications 1, 2
• Emergency surgery (odds ratio 4.47 for pulmonary complications) 2
• Prolonged surgery (>3-4 hours) (odds ratio 2.14) 2

Surgical Procedures

• Abdominal operations (upper abdominal surgery carries highest risk) 1, 2, 3
• Thoracic operations 3
• Head and neck operations 3
• Rib fractures, particularly ≥3 displaced fractures or flail chest 4

Physiologic Rationale

Incentive spirometry aims to prevent postoperative pulmonary complications through sustained maximal inspiratory effort, which theoretically:

• Increases lung volumes and prevents atelectasis 1
• Improves alveolar recruitment 1
• Enhances gas exchange 1

However, the evidence demonstrates that IS provides no measurable advantage over simple deep breathing exercises in achieving these goals. 1, 2, 5

Evidence Quality and Effectiveness

Critical Evidence Limitations

The American College of Physicians guidelines establish that any lung expansion modality is superior to no prophylaxis after abdominal surgery, but no single technique clearly outperforms the others. 1, 2

Key research findings reveal significant limitations:

• Cochrane reviews found no evidence that IS reduces pulmonary complications compared to other physiotherapy interventions in upper abdominal surgery (12 studies, 1834 participants) 5 or coronary artery bypass graft (7 studies, 592 participants) 6, 7
• IS demonstrated worse pulmonary function and arterial oxygenation compared to positive pressure breathing techniques (CPAP, BiPAP, IPPB) 1, 6, 7
• A 2018 randomized controlled trial of 387 patients undergoing lung resection found no difference in postoperative pulmonary complications between IS plus physiotherapy (12.3%) versus physiotherapy alone (13.0%) 8
• Incentive spirometry alone provides no additional benefit over deep breathing exercises 2

Contradictory Evidence

One non-randomized pilot study (263 patients) suggested IS as part of intensive physiotherapy decreased pulmonary complications (6% vs 17%) 9, but this conflicts with higher-quality randomized trials and should be interpreted cautiously given methodological limitations.

Proper Technique and Protocol

Positioning and Execution

• Sit upright when using the incentive spirometer for optimal lung expansion 4, 3
• Take a slow, deep breath through the mouthpiece 4, 3
• Hold breath for 3-5 seconds before exhaling 4, 3

Frequency and Duration

• Perform 10 maximal inspiratory maneuvers every hour while awake 4, 3
• Continue for at least 2-4 weeks postoperatively to prevent respiratory complications 4, 3

Integration with Multimodal Care

IS should never be used as the sole intervention but rather as part of comprehensive pulmonary care. 2, 3 The multimodal approach includes:

Essential Components

• Early mobilization: Out of bed on day of surgery, progressing from moving in bed to sitting, standing, and walking 2, 3
• Deep breathing exercises: 10-30 deep breaths per hour while awake 4, 2
• Supported coughing: Splinting the incision site when coughing 4, 2
• Adequate pain control: Essential to facilitate effective deep breathing and IS use 2, 3

Evidence for Multimodal Approach

An intensive physiotherapy program including IS reduced postoperative pulmonary complications from 15.5% to 4.7% compared to controls, demonstrating that multimodal programs are more effective than isolated interventions 4

Superior Alternatives for Specific Situations

When Patients Cannot Perform IS Effectively

Nasal continuous positive airway pressure (CPAP) at 8-10 cm H₂O for 8-12 hours following extubation is superior to standard oxygen therapy for hypoxemic patients who are unable to perform IS or deep breathing exercises 1, 2, 3

Neuraxial Blockade

Neuraxial blockade reduces the risk of pneumonia (odds ratio 0.61) and should be considered as part of the anesthetic plan for high-risk patients 2

Nasogastric Tube Management

Use selective rather than routine nasogastric decompression, inserting only if postoperative nausea, vomiting, or symptomatic distention occurs, as routine placement increases pulmonary complications 2

Common Pitfalls and How to Avoid Them

Critical Errors to Avoid

• Relying on IS alone without deep breathing exercises and mobilization is ineffective 2, 3
• Applying IS to low-risk patients wastes resources without benefit 3
• Inadequate pain control prevents effective IS use 2, 3
• Delaying mobilization reduces overall effectiveness of pulmonary hygiene 2
• Routine nasogastric tube placement increases pulmonary complications 2
• Using preoperative spirometry for risk prediction does not translate to effective individual risk assessment 2

Implementation Considerations

Preoperative education is essential for patients at high risk for complications, ensuring proper technique through demonstration and supervision 2

Special Population: Chest Trauma

For patients with rib fractures:

• IS is specifically recommended for multiple (≥3) displaced fractures as these patients are at high risk for respiratory complications 4
• Combine with regional anesthesia techniques to facilitate better use when severe pain is present 4
• Integrate with ice application (15-20 minutes several times daily) to reduce pain and inflammation 4

Clinical Bottom Line

Deep breathing exercises are more labor-efficient than IS alone and should be the primary intervention, with IS serving as an adjunct device that may help some patients achieve sustained maximal inspiration 2. The device's main value lies in providing visual feedback and a structured approach to deep breathing, not in any inherent superiority over coached deep breathing exercises. For patients who cannot perform these maneuvers effectively, CPAP or NIPPV should be considered instead. 2, 3