When and how should incentive spirometry be used in patients at risk for postoperative or immobilization‑related pulmonary complications?

Incentive Spirometry for Postoperative Pulmonary Complications

All patients at higher risk for postoperative pulmonary complications should receive postoperative incentive spirometry combined with deep breathing exercises—not incentive spirometry alone. 1

When to Use Incentive Spirometry

Patient Risk Factors Requiring Intervention

Identify patients with any of the following significant risk factors who should receive postoperative incentive spirometry: 1

• Chronic obstructive pulmonary disease (most commonly identified risk factor, OR 1.79)
• Age >60 years (OR 2.09 for ages 60-69; OR 3.04 for ages 70-79)
• ASA class ≥II
• Functionally dependent status
• Congestive heart failure
• Low serum albumin <35 g/L (powerful marker requiring measurement in suspected hypoalbuminemia) 1

High-Risk Surgical Procedures Requiring Intervention

Patients undergoing these procedures are at elevated risk and should receive postoperative interventions: 1

• Prolonged surgery (>3 hours)
• Abdominal surgery
• Thoracic surgery
• Neurosurgery
• Head and neck surgery
• Vascular surgery
• Aortic aneurysm repair
• Emergency surgery
• General anesthesia

Important caveat: Obesity and mild-to-moderate asthma are NOT significant risk factors for postoperative pulmonary complications. 1

How to Use Incentive Spirometry

Critical Implementation Strategy

Incentive spirometry must be combined with other interventions—it should never be used as a standalone therapy. The American College of Physicians explicitly recommends incentive spirometry be used together with: 1

1. Deep breathing exercises
2. Directed coughing
3. Early mobilization
4. Optimal analgesia

This multimodal approach is essential because incentive spirometry alone has not demonstrated effectiveness in preventing postoperative pulmonary complications. 2

Specific Protocol Parameters

While the evidence shows variability in protocols, recent research suggests the following approach for optimal compliance and outcomes: 3, 4, 5

• Frequency: Bihourly use for 48 hours post-extubation 3
• Volume-oriented device preferred over flow-oriented devices 2
• Preoperative training (when feasible) improves postoperative compliance and technique, reducing complications from 24.4% to 5.9% 5
• Target parameters that predict success: ≥5 repetitions per day and ≥2 balls raised per repetition 5

Evidence Strength and Nuances

The guideline evidence from the American College of Physicians (2006) remains the authoritative source, though it acknowledges that deep breathing exercises alone provide equivalent benefit to incentive spirometry. 2 This explains why the combination approach is mandated rather than incentive spirometry in isolation.

More recent research (2021-2023) shows benefits specifically in cardiac surgery populations, with reductions in hypoxic events, atelectasis (20% vs 42.5%), mechanical ventilation duration, and hospital length of stay. 3, 4, 6 However, these studies examined incentive spirometry as part of comprehensive respiratory care protocols, not as monotherapy.

Common pitfall to avoid: Do not use incentive spirometry routinely after upper abdominal surgery or coronary artery bypass graft surgery as the sole intervention—it lacks evidence for effectiveness in this context. 2 Always combine with the multimodal approach described above.

What NOT to Do

• Do not perform preoperative spirometry or chest radiography routinely for risk prediction (only appropriate in patients with known COPD or asthma) 1
• Do not use incentive spirometry alone without deep breathing exercises, early mobilization, and adequate pain control 1, 2
• Do not rely on incentive spirometry as a substitute for early ambulation or directed coughing 2