Incentive Spirometry: Evidence-Based Approach
Incentive spirometry (IS) should not be used as a standalone intervention but rather integrated into multimodal postoperative respiratory care, and only in high-risk surgical patients—it provides no benefit in low-risk patients and should be avoided in that population. 1, 2
Patient Selection: Who Benefits from IS
High-risk patients who should receive IS as part of comprehensive care include: 2, 3
- Patients undergoing abdominal, thoracic, head, or neck operations 2
- Those with COPD (particularly with FEV1 <60% predicted) 4, 5
- Patients with musculoskeletal chest wall abnormalities 2
- Age >60-75 years 2
- Multiple (≥3) displaced rib fractures or flail chest 3
Low-risk patients should NOT receive IS, as controlled trials demonstrate no benefit and it wastes resources. 6
Proper Technique and Frequency
The technique matters for effectiveness: 2, 3
- Position: Sit upright for optimal lung expansion 2, 3
- Breathing pattern: Take a slow, deep breath through the mouthpiece, hold for 3-5 seconds, then exhale 2, 3
- Frequency: Perform 10 maximal inspiratory maneuvers every hour while awake 2, 3
- Duration: Continue for at least 2-4 weeks postoperatively 2, 3
Critical Integration with Multimodal Care
IS must be part of—not added to—comprehensive pulmonary care. The evidence is clear that IS alone provides no benefit: 1, 2
Essential concurrent interventions:
- Early mobilization: Out of bed on day of surgery 2, 3
- Deep breathing exercises: 10 times every hour while awake 2, 3
- Supported coughing: Splinting the painful area with a pillow 3
- Adequate pain control: Essential for effective IS use 1, 2, 3
A landmark study in thoracic surgery patients found that adding IS to standard physiotherapy (thoracic expansion exercises, supported coughing, early mobilization) showed no difference in complication rates or hospital length of stay. 1
Evidence Quality and Nuances
The evidence reveals important distinctions:
In thoracic surgery generally: Multiple high-quality trials show IS adds no benefit to multimodal care. 1, 7
In COPD patients specifically: Emerging evidence suggests IS may reduce postoperative pulmonary complications when FEV1 <80% predicted, with a 32% risk reduction and 1.8-day shorter hospital stay. 5 However, this must still be combined with smoking cessation (4-8 weeks preoperatively), early mobilization, and effective analgesia. 1, 2
In low-risk patients: A controlled trial in ASA class 1-2 patients undergoing cholecystectomy found no difference in radiologic complications, oxygenation, or spirometry between IS and no specialized respiratory care. 6
When IS Cannot Be Performed Effectively
If patients cannot perform IS or deep breathing exercises due to pain or inability: 2
- CPAP or NIPPV at 8-10 cm H₂O for at least 8-12 hours following extubation is superior to standard oxygen therapy 1, 2
- This is particularly important in obese patients, where CPAP immediately post-extubation reduces atelectasis and improves oxygenation 1
Common Pitfalls to Avoid
Do not use IS as sole intervention—this is ineffective and wastes resources. 1, 2
Do not apply to low-risk patients—evidence shows no benefit and diverts attention from interventions that matter. 6
Do not delay early mobilization—this is more important than IS itself. 1, 2
Do not use in COPD patients with bullae—risk of pneumothorax outweighs potential benefits. 8
Ensure adequate pain control first—without this, IS use will be ineffective regardless of patient effort. 1, 2, 3
Special Populations
Head and neck surgery with tracheostomy: IS can be used with appropriate adaptors and shows improvement in lung function without complications. 7
Rib fractures in elderly: IS is specifically indicated as part of multimodal care including pain management (acetaminophen first-line, cautious NSAID use), ice application, and deep breathing exercises. 3