Is incentive spirometry (IS) beneficial for patients after a surgical procedure?

Incentive Spirometry After Surgery: Evidence-Based Recommendation

Incentive spirometry should be used as part of multimodal respiratory care for high-risk surgical patients, but it provides no additional benefit over deep breathing exercises alone and should never be used as a standalone intervention. 1, 2

Patient Selection: Who Benefits Most

High-risk patients who warrant lung expansion therapy include those with: 2, 3

• Age >60 years (strongest patient-related risk factor) 3
• Chronic obstructive pulmonary disease 1, 3
• ASA class II or higher 1, 3
• Functional dependence 1, 3
• Congestive heart failure 1, 3
• Low serum albumin (<35 g/L) (one of the most powerful predictors) 3

Procedure-related risk factors include: 2, 3

• Abdominal surgery (especially laparotomy) 1, 3
• Thoracic surgery 1, 2
• Head and neck surgery 1, 2
• Prolonged surgery (>3-4 hours) 3
• Emergency surgery 1, 3

The Evidence: No Superiority Over Simpler Alternatives

The American College of Physicians guideline establishes that any lung expansion modality is superior to no prophylaxis after abdominal surgery, but no single technique clearly outperforms the others. 1 This is a critical finding—incentive spirometry works, but so do deep breathing exercises, and neither is superior to the other. 1

A 2012 Cochrane review of 592 patients undergoing coronary artery bypass graft found no evidence of benefit from incentive spirometry in reducing pulmonary complications compared to physical therapy alone, and patients treated with incentive spirometry actually had worse pulmonary function and arterial oxygenation compared to positive pressure breathing techniques. 4 Similarly, a 1997 randomized trial of 185 high-risk CABG patients found no difference between incentive spirometry plus physical therapy versus physical therapy alone in atelectasis, spirometry, oxygen saturation, pulmonary infection, or hospital stay. 5

However, one 2007 nonrandomized study of 263 patients undergoing major abdominal surgery showed decreased pulmonary complications (6% vs 17%, p=0.01) when incentive spirometry was added to an intensive physiotherapy program. 6 A 2021 review suggests emerging evidence of benefit specifically in higher-risk populations such as those with COPD undergoing thoracic surgery. 7

Proper Implementation Protocol

Technique: 2, 8

• Patients must sit upright for optimal lung expansion 2, 8
• Take a slow, deep breath through the mouthpiece 2, 8
• Hold breath for 3-5 seconds before exhaling 2, 8

Frequency: 2, 3

• Perform 10 maximal inspiratory maneuvers every hour while awake 2, 3
• Continue for at least 2-4 weeks postoperatively 2, 8

Essential Multimodal Components (Never Use Incentive Spirometry Alone)

Incentive spirometry must be integrated with: 2, 3

1. Early mobilization - patients should be out of bed on the day of surgery 2, 3
2. Deep breathing exercises - 30 deep breaths per hour while awake 3
3. Supported coughing - splinting the incision site 3
4. Adequate pain control - essential to prevent ineffective use 2, 3
5. Selective nasogastric tube use - only if postoperative nausea, vomiting, or symptomatic distention occurs (routine use increases pneumonia and atelectasis) 1, 3

When to Use Alternative Approaches

For patients unable to perform incentive spirometry or deep breathing exercises effectively: 2, 3

• CPAP or noninvasive positive pressure ventilation (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
• Neuraxial blockade reduces pneumonia risk (odds ratio 0.61) 3

Critical Pitfalls to Avoid

Do not: 2, 3

• Use incentive spirometry as the sole intervention without multimodal care 2, 3
• Apply to low-risk patients (unnecessary resource utilization) 2
• Place routine nasogastric tubes (increases pulmonary complications) 1, 3
• Delay early mobilization 2, 3
• Provide inadequate pain control (prevents effective deep breathing) 2, 3
• Rely on preoperative spirometry for individual risk prediction (does not translate to effective risk assessment) 3

Clinical Bottom Line

Deep breathing exercises are more labor-efficient than incentive spirometry alone and should be the primary intervention, with incentive spirometry serving as a motivational tool for patients who respond to device-guided therapy. 3 The device may help some patients maintain adherence to breathing exercises, but the breathing itself—not the device—is what prevents complications. 7 For high-risk patients, particularly those with COPD undergoing thoracic or abdominal surgery, the combination of incentive spirometry with comprehensive pulmonary care is reasonable, but never expect the device alone to reduce complications. 7, 6