The Efficacy of Postoperative Incentive Spirometry Is Influenced by the Device-Specific Imposed Work of Breathing

doi:10.1378/chest.119.6.1858

Chest

Volume 119, Issue 6, June 2001, Pages 1858-1864

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Study objectives

The study evaluated the impact of the additional imposed work of breathing (WBimp) generated by two different spirometers on postoperative incentive spirometry performance in patients at high risk and moderate risk for postoperative pulmonary complications (PPCs). Additionally, we investigated whether maximal inspiratory pressure (Pimax) is an easy estimate of the WBimp imposed by incentive spirometers.

Design

Prospective, randomized, single-blind clinical trial.

Setting

ICU of a university hospital.

Interventions and measurements

Thirty male patients were assigned to a group at high risk for PPCs (group A; inspiratory capacity [IC], < 1.6 L) or to a group at moderate risk for PPCs (group B; IC, 1.6 to 2.5 L) after upper-abdominal, thoracic, or two-cavity surgery. On the first or second postoperative day WBimp, IC, and Pimax were recorded without spirometers (baseline) and during incentive spirometry with the Mediflo spirometer (Medimex; Hamburg, Germany) (high WBimp) and the Coach spirometer (Kendall; Neustadt, Germany) (low WBimp) using a pneumotachograph. In group A, the baseline and the ICs for both spirometers only differed slightly. In group B, the IC was significantly reduced for the Mediflo (p < 0.05), which imposed a WBimp twice as high as the Coach (p < 0.01). Pimax was significantly increased for both the Mediflo and the Coach (p < 0.01). Pimax was positively correlated with WBimp (r = 0.8).

Conclusions

Incentive spirometers differ considerably in their additional Wbimp with a potential impact on the efficacy of postoperative incentive spirometry performance. Pimax might be an easy clinical estimate for the WBimp during incentive spirometry. Incentive spirometers with low WBimp permit increased maximal sustained inspiration and, thus, enhanced incentive spirometry performance, and, therefore, it might be more suitable for use in postoperative respiratory care.

Section snippets

Patients

After the study was approved and written informed consent was obtained, 30 male patients were included in the study after undergoing elective upper-abdominal, thoracic, or two-cavity surgery. To avoid the influence of well-known, significant, gender-specific differences in functional respiratory parameters, only male patients were included in the study. Depending on postoperative inspiratory capacity (IC) and the subsequent risk for PPCs, patients were assigned to a group of patients at high

Biometric Data

In each group, 15 patients were included. Both groups were very comparable concerning mean (± SD) age (group A, 50.3 ± 14.7 years; group B, 51.7 ± 12.7 years), mean height (group A, 173 ± 6:1 cm; group B, 172 ± 3.8 cm), and mean weight (group A, 75 ± 16.0 kg; group B, 66.4 ± 8.1 kg). The observed differences were not significant (Table 1).

IC

In group A, the mean baseline IC (1.26 ± 0.18 L) and the mean ICs using the Mediflo (1.32 ± 0.45 L) or the Coach (1.29 ± 0.33 L) differed only slightly, and

Discussion

The therapeutic efficacy of incentive spirometry is controversially discussed in the literature.^3,^7,^8,^9,^10,^11,^12,^13,¹⁴ However, manifold variables, whether patient-related (eg, age, constitution, or concomitant pulmonary disease) or care-related (eg, type of surgery, anesthesia, or analgesia), are supposed to have an impact on the efficacy of respiratory care and yielded inconsistent results. Clinical observations indicate that not every patient will benefit from respiratory care. Schwieger et

Conclusion

In conclusion, different types of incentive spirometers differ considerably in their additional WBimp in the clinical setting. These differences seem to be clinically relevant because of their impact on postoperative incentive spirometry performance. Thus, incentive spirometers with a low additional WBimp allow improved maximal sustained inspiration and therefore might be more suitable for postoperative respiratory training. Additionally, when considering the efficacy of incentive spirometry in

ACKNOWLEDGMENT

We are indebted to Joan Robertson-Hoehne for language assistance and copyediting the article.

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Incentive spirometer: Aspects of the clinical practice of physical therapists from Minas Gerais working with patients with respiratory dysfunction
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Incentive spirometers (ISs) are clinical devices used in respiratory physical therapy to increase alveolar ventilation and functional residual capacity.
To investigate factors that influence physical therapists from Minas Gerais in selecting a type of IS and the scientific background behind the use of ISs by physical therapists who work with patients with respiratory dysfunctions.
Physical therapists from 13 hospital and non-hospital institutions (public/private) completed a self-administered questionnaire based on the current evidence on ISs.
Indications and contraindications of ISs are not fully understood by most of the 168 physical therapists who completed the questionnaire. Volume-oriented IS was preferred over flow-oriented IS. However, only half of the physical therapists have a scientific background to justify the choice of one IS type rather than the other.
Most physical therapists from Minas Gerais do not fully understand the indications and contraindications for ISs. Despite physical therapists stating their preference for volume-oriented IS, this choice is not necessarily based on current scientific evidence. The development of strategies to bring physical therapists closer to evidence-based practice is necessary to ensure best patient care.
Effectiveness of Incentive Spirometry on Inspiratory Muscle Strength After Coronary Artery Bypass Graft Surgery
2020, Heart Lung and Circulation
Although the use of incentive spirometry with a deep breathing exercise (DBE) is widely used in clinical practice in patients who have undergone coronary artery bypass graft (CABG) surgery, the effect of this combination therapy has not been conclusively elucidated. The aim of this study was to investigate the effect of postoperative combined incentive spirometry and DBE versus DBE alone on inspiratory muscle strength following CABG.
This randomised clinical trial was conducted in patients scheduled to undergo CABG surgery at Siriraj Hospital, Bangkok Thailand. The study group received incentive spirometry and DBE, and the control group received DBE only. Maximal inspiratory pressure (MIP) before surgery and at day 4 after surgery was assessed by a respiratory pressure meter. Secondary outcomes, including postoperative pulmonary complication and duration of postoperative hospitalisation, were obtained from the medical records.
Ninety (90) patients were included, with 47 and 43 patients assigned to the study and control groups, respectively. In both groups, there was a significant reduction in MIP from preoperative baseline to postoperative day 4; however, the MIP in the incentive spirometry group had a significantly smaller reduction in MIP compared with the control group (33.0±23.2% vs 47.2±20.1%, respectively; p=0.006, 95% confidence interval, 3.9-23.3). There was no difference between groups regarding secondary outcomes.
Patients in the study group had significantly better recovery of inspiratory muscle strength on day 4 post-CABG than patients in the control group. There was no significant difference between groups for either postoperative pulmonary complications or length of hospital stay.
Sustained maximal inspiration has similar effects compared to incentive spirometers
2019, Respiratory Physiology and Neurobiology
Citation Excerpt :
Therefore, we may consider that VIS was the exercise that better met the principles proposed by the technique. Previous studies have shown that FIS imposed greater work of breathing than VIS (Mang and Obermayer, 1989; Weindler and Kiefer, 2001). Using artificial lungs, Mang and Obermayer (1989) compared six different incentive spirometers and observed that FIS models imposed greater work of breathing when compared with VIS models.
To compare the effects of flow incentive spirometer (FIS), volume incentive spirometer (VIS), and sustained maximal inspiration exercise (SMI) on breathing pattern, chest wall motion, and thoracoabdominal asynchrony.
Sixteen healthy adults aged 27.63 ± 5.26 years were evaluated by optoelectronic plethysmography in the supine position with trunk inclination of 45° during quiet breathing and during exercise performance.
In the comparisons among exercises, VIS promoted a significantly higher inspiratory time and lower mean inspiratory flow compared with FIS. The rating of perceived exertion according to the Borg Scale was significantly higher after the performance of FIS compared with VIS. Regarding asynchrony, none of the exercises caused changes in thoracoabdominal synchrony between the rib cage and abdomen. However, both devices significantly reduced the asynchrony between the pulmonary and abdominal rib cage compared with quiet breathing.
SMI exercise was equivalent to incentive spirometers and may be an interesting alternative for clinical use in cases in which it is not possible to acquire the devices.
Inspiratory muscle training with threshold or incentive spirometry: Which is the most effective?
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Inspiratory muscular training (IMT) increases the respiratory muscle strength, however, there is no data demonstrating its superiority over the incentive spirometry (IS) in doing so. Values of muscle strength after IMT (Threshold IMT^®) and by the IS (Voldyne^®) in healthy females was compared. Subjects (n = 40) were randomly divided into control group (CG, n = 14), IS group (ISG, n = 13) and threshold group (TG, n = 13). PI_max was measured before (pre-IMT), at 15 and 30 days of IMT. There was an increase in PI_max of the TG at 15 days (p < 0.001) and 30 days of IMT (p < 0.001). The same occurred with the ISG, which increased the PI_max at 15 days (p < 0.001) and 30 days of training (p < 0.001). After 30 days of IMT, the TG presented a PI_max which was significantly higher than ISG and the CG (p = 0.045 and p < 0.001, respectively). It can be concluded that IMT by threshold was more effective in increasing muscle strength than the Voldyne.
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Maintaining large inflating volumes and transpulmonary pressures for several seconds are necessary to achieve alveolar recruitment since obstructed areas have longer time constants. In contrast IS involves the use of incentive spirometers which are instrumental devices that offer the additional benefit of visual feedback, in terms of flow or volume, giving the patient a measurable goal while performing the BE (Weindler and Kiefer, 2001; Agostini and Singh, 2009). Since 1980’s, IS became widely used in the postoperative of thoracic and abdominal surgeries for the prevention and treatment of pulmonary complications (O’Donohue, 1985).
Breathing exercises (BE), incentive spirometry and positioning are considered treatment modalities to achieve lung re-expansion. This study evaluated the influence of incentive spirometry and forward leaning on inspired tidal volumes (V_T) and electromyographic activity of inspiratory muscles during BE. Four modalities of exercises were investigated: deep breathing, spirometry using both flow and volume-oriented devices, and volume-oriented spirometry after modified verbal instruction. Twelve healthy subjects aged 22.7 ± 2.1 years were studied. Surface electromyography activity of diaphragm, external intercostals, sternocleidomastoid and scalenes was recorded. Comparisons among the three types of exercises, without considering spirometry after modified instruction, showed that electromyographic activity and V_T were lower during volume-oriented spirometry (p = 0.000, p = 0.054, respectively). Forward leaning resulted in a lower V_T when compared to upright sitting (p = 0.000), but electromyographic activity was not different (p = 0.606). Inspired V_T and electromyographic activity were higher during volume-oriented spirometry performed after modified instruction when compared with the flow-oriented device (p = 0.027, p = 0.052, respectively). In conclusion BE using volume-oriented spirometry before modified instruction resulted in a lower work of breathing as a result of a lower V_T and was not a consequence of the device type used. Forward leaning might not be assumed by healthy subjects during situations of augmented respiratory demand.
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: This study was financed entirely by university scientific budgets.

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Chest

Clinical Investigations in Critical CareThe Efficacy of Postoperative Incentive Spirometry Is Influenced by the Device-Specific Imposed Work of Breathing

Study objectives

Design

Setting

Interventions and measurements

Conclusions

Section snippets

Patients

Biometric Data

IC

Discussion

Conclusion

ACKNOWLEDGMENT

Chest

Chest

Lancet

Thorac Cardiovasc Surg

Chest

Lancet

Crit Care Clin

Studies on the pathogenesis and prevention of postoperative pulmonary complications

Surg Gynecol Obstet

Are incentive spirometers, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper-abdominal surgery: a systematic overview and meta-analysis

Phys Ther

Postoperative atemtherapie mit incentive spirometry

Anaesthesist

Clinical Investigations in Critical Care
The Efficacy of Postoperative Incentive Spirometry Is Influenced by the Device-Specific Imposed Work of Breathing