Is an incentive spirometer recommended for a patient with a sternal fracture?

Incentive Spirometry for Sternal Fractures

Yes, patients with sternal fractures should use an incentive spirometer as part of a comprehensive respiratory care protocol to prevent pulmonary complications, particularly atelectasis and pneumonia. 1, 2

Evidence-Based Rationale

The recommendation for incentive spirometry in sternal fractures is extrapolated from high-quality evidence in rib fracture management, as both injuries share similar pathophysiology: pain-induced splinting leads to shallow breathing, reduced lung volumes, and increased risk of respiratory complications. 1, 3

Key Supporting Evidence

• Multimodal respiratory care including incentive spirometry reduces pulmonary complications from 15.5% to 4.7% in chest trauma patients compared to controls. 2

• Bedside incentive spirometry volumes predict pulmonary complication risk in patients with chest wall injuries—admission volumes <1000 mL are associated with 3.3× relative risk of complications. 3

• Incentive spirometry increases maximal inspiratory volume by 16% over 30 days when used consistently (from 1885 mL to 2235 mL baseline), demonstrating measurable physiologic benefit. 4

Proper Implementation Protocol

Technique (per CDC and American Thoracic Society guidelines)

• Sit upright when using the device for optimal lung expansion. 2

• Take slow, deep breaths through the mouthpiece, holding for 3-5 seconds before exhaling. 1, 2

• Perform 10 repetitions every hour while awake. 2

• Continue for 2-4 weeks minimum to prevent respiratory complications. 1, 2

Integration with Comprehensive Care

Incentive spirometry must not be used in isolation—it should be part of a multimodal pulmonary hygiene program that includes: 2

• Early mobilization and progressive ambulation. 1, 2

• Deep breathing exercises performed 10 times every hour. 2

• Supported coughing techniques (splinting the painful area with a pillow). 1, 2

• Adequate pain control to enable effective respiratory exercises—multimodal analgesia with acetaminophen as first-line, NSAIDs for breakthrough pain, and opioids reserved strictly for severe refractory pain. 1, 2

Clinical Context for Sternal Fractures

When Admission May Be Required

Most isolated sternal fractures (88%) do not require hospitalization for respiratory management alone. 5 However, admission is warranted for: 5

• High-impact trauma mechanisms
• Severely displaced fractures
• Significant associated injuries
• Complex analgesic requirements preventing adequate respiratory effort
• Important cardiopulmonary comorbidities
• Inadequate domestic support for outpatient respiratory care

Contraindications to Spirometry

While incentive spirometry is generally safe, defer spirometry testing (not incentive spirometry use) if: 6

• Hemodynamic instability is present
• Recent thoracic surgery within 2-4 weeks
• Acute myocardial infarction or unstable angina
• Active pneumothorax
• Hemoptysis of unknown origin

Important distinction: These contraindications apply to formal spirometry testing for pulmonary function assessment, not to therapeutic incentive spirometry use, which remains indicated for respiratory care. 6

Expected Recovery Timeline

• Pain improvement should be significant by 4 weeks with appropriate management. 1, 2

• Sternal fractures typically heal within 6-8 weeks. 1, 2

• Respiratory function should show progressive improvement over 2-4 weeks with consistent incentive spirometry use. 2

• Complete functional recovery takes 8-12 weeks. 1

Critical Warning Signs Requiring Immediate Evaluation

Instruct patients to seek immediate medical attention for: 1, 2

• Worsening dyspnea or respiratory distress
• Fever >100.4°F (38°C)
• Productive cough with yellow, green, or bloody sputum
• Progressive oxygen desaturation
• Chest pain different from the fracture pain, especially with dyspnea or dizziness
• Confusion or altered mental status

Common Pitfalls to Avoid

• Under-treatment of pain leads to immobilization, shallow breathing, poor cough effectiveness, atelectasis, and pneumonia. 1

• Excessive opioid reliance causes respiratory depression, particularly dangerous in elderly patients with sternal fractures. 1, 2

• Failing to implement early respiratory physiotherapy results in preventable pulmonary complications. 1

• Using incentive spirometry alone without mobilization is less effective than multimodal approaches. 2