RUNNING HEAD: PICOT Paper 1

Does the use of incentive spirometry in hospitalized patients decrease the risk of pulmonary

complications compared to those who do not use incentive spirometry?

Sarah Perfetuo

University of New Hampshire

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In nearly every patient room in the hospital setting, an incentive spirometer is readily

available at the bedside. It seems as though these are handed to anyone who is in a hospital bed

for a stretch of time, especially post-operatively. These devices are given to patients to prevent

pulmonary atelectasis, which is the collapse of the alveoli in our lungs. The lack of lung

inflation is caused by the shallowness of breathing, prolonged recumbent positioning, and

temporary diaphragmatic dysfunction (Overend 972). Atelectasis can then cause pneumonia,

which of course in the hospital is something to be avoided at all costs. Overall, these devices are

meant to keep the lungs at their optimal level of function while the patient is confined to bed or

at all compromised. The patient is instructed to use the incentive spirometer five to ten times for

every hour of being awake, depending on the facilitys protocol; visual feedback is obtained

when the patient inhales into the device, which for some can be a motivating factor to continue to

use the device. However, the incentive spirometers efficacy remains unclear in the health care

field, not backed by clinical evidence. The purpose of this paper is the further investigate and

gather evidence on if incentive spirometry use is effective in decreasing the risk of pneumonia

and other pulmonary complications in hospitalized patients.

Evidence is imperative to nursing practice to ensure that patients are receiving care that is

up-to-date, relevant, and will improve their outcomes. Evidenced based practice is something

that should be utilized because it means that nursing knowledge is being used in clinically useful

forms that will positively impact health care outcomes for patients. When all the interventions

nurses provide are backed by clinically significant evidence and research findings, desired

outcomes are more likely to be achieved, and the patient will be the safest.

To begin my research, I used the UNH library website to search various databases

through EBSCO host as my search engine. An additional search engine I used was the
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Search MEDLINE/PubMed via PICO with Spelling Checker; with this, each component of the

PICOT question can be inputted to generate articles pertaining to the search criteria. Within these

search engines, the data bases I used were MEDLINE, PubMed, CINAHL complete, Cochrane

Database of Systematic Reviews, and Health Source: Nursing/Academic Edition. When

searching using EBSCO host, the key words I inputted were incentive spirometry,

pneumonia, pulmonary complications, respiratory interventions, and hospitalized

patients. When using the Search MEDLINE/PubMed via PICO with Spelling Checker, I

simply entered the key words in my PICO question piece by piece into each letter. For P-

Patient/Problem (also known as Medical condition for this particular search engine), I entered

pneumonia or pulmonary complications. For I- Intervention, I entered incentive

spirometry. For C- compare to, I entered pulmonary complications. Lastly, O- Outcome was

an optional criterion so I left it blank to see what results I could generate without it. A limiter

used on the searches was full text, because I was finding that articles were being included in

my results that were not accessible without a purchase or a paid membership to certain websites.

Another limiter was abstract available, and setting the language to English only. After

browsing through 19 results from EBSCO host, and 24 results from Search MEDLINE/PubMed

with Spelling Checker, five articles were chosen that best support and provide information

relating to the PICO question. Inclusion criteria were any articles and or studies that took place

within the last 10 years, of English language, randomized control trials of incentive spirometry,

systematic reviews of various trials, observational studies, and articles from credible databases.

Exclusion criteria were any articles not of the English language, took place more than 10 years

ago, study populations not appropriate (too small), or any articles that posed any biases.
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The first source that I looked at was a systematic review of eight studies, titled The

effect of incentive spirometry on postoperative pulmonary complications: a systematic review.

These studies were obtained through primary searches of computerized databases, using key

words such as incentive spirometry, breathing exercises, and pulmonary complications.

Each of those studies were investigated to find out what the primary result was of the effects of

incentive spirometry (IS). A noted strength of this study was the intense reviews each of the

studies went through before being selected. The studies were appraised and critiqued based on

multiple factors. For example, studies were excluded if its design did not properly answer the

research question at hand, or if the study population was not appropriate. A weakness of this

study was that even with the selected studies that were thought to be credible, there was still

uncertainty with patient compliance with the treatment. Even if the intervention of IS or

breathing exercises is explained and demonstrated to the patient, unless the researcher is in the

room for every single time, there is no true way to know if the patient was 100% compliant with

the instructions, thus skewing the data.

The next source I looked at was a credible Clinical Practice Guideline, titled AARC

Clinical Practice Guideline - Incentive Spirometry: 2011. The guideline was formed based on a

review of 54 clinical trials and systematics reviews on incentive spirometry; articles were

searched using MEDLINE, CINAHL, and Cochrane Library databases. The purpose was to gain

more research and insight on incentive spirometry, since its clinical efficacy remains unclear. A

strength of this study was the variety of settings that were included; they integrated studies from

critical care units, acute in-patient care, extended care and skill nursing facilities, and home care.

Most of the other articles were just studying postoperative incentive spirometry use, so this was

an interesting element. A weakness of this study was lack of control of how effective the
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incentive spirometry teaching was. If the training for the IS is inadequate, the patient will be

insufficient with the self-administration of the intervention. This can result in lack of resolution

of post-operative complications if the patient does not know how to properly use the device

(Restrepo 1601). This is important to note for practice; effective patient teaching and careful

instruction can make a difference for better or worse.

The last source I reviewed was an observational study conducted over eight months of all

patients post-operatively recovering from an operation where the abdomen or chest was opened.

For the first fourth months, patients were receiving standard chest physiotherapy (coughing and

deep breathing with inspiratory hold and stiff regimen taking place every half an hour). For

the final four months, the patients continued to receive the standard chest physiotherapy, except

there was no inspiratory hold and stiff; instead, the deep breaths were performed using the

incentive spirometer five times every half an hour. The two different interventions were

compared against one another based off of length of hospital stay, post-operative pulmonary

complications (PPCs), and time spent by physiotherapy staff with each patient. A strength of

this study was from the beginning, patients with pre-existing respiratory comorbidities, including

a smoking history, were identified and factored in to the results. Another strength was the

continuity of staff and protocols during the study; no changes in nursing or physiotherapy staff

were implemented, and no new protocols that were affect patient care or length of hospital stay

were introduced. A weakness of this study was the lack of other objective measurements to

further investigate respiratory function under each intervention. Measurements such as

expiratory flow, FEV1, or FVC could have been noted in addition to the inspiratory flow.

Between the three studies I appraised for evidence, they all had similar results and

findings regarding incentive spirometry. The biggest issue was determining if incentive
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spirometry was an effective modality on its own; It was not possible to isolate the effect of IS

from that of other treatments, thus no valid conclusions could be drawn about the effect of IS.

(Overend 973). My first source, the systematic review, identified eight acceptable studies that

investigated the effects of an IS treatment program, either as a stand-alone treatment or as an

adjunct treatment. Seven of the eight studies failed to support any positive effect of IS.

(Overend 975). Of eight studies that were reviewed, half of them were conducted post-

abdominal surgery, and the other half were conducted post-cardiac surgery. But regardless of the

procedure, the findings were consistent that evidence was not sufficient enough to support

positive outcomes using IS. However, this does not mean that IS poses disadvantages to the

patient. Incentive spirometry has potential in its efforts; effective inspiratory efforts are

optimized by patients achieving a visual 'target'; this visual feedback promotes patient

compliance; following instruction patients can use the device independently and at will;

instruction in using the device is simple and the device is cheap and disposable. Despite these

potential advantages, the majority of evidence does not support the hypothesis that IS is superior

to other post-operative physiotherapy techniques or assisted lung expansion. However, this

evidence is generally of low quality. (Westwood 341). Across the board, evidence showing

incentive spirometry as an effective means of preventing pulmonary complications is lacking. It

has not been associated with any improvements of inspiratory capacity, decrease in pulmonary

complications, and has no proven usefulness in preventing decrease in overall lung function post-

operatively. On the other hand, there is concrete evidence saying that maximal inspiratory

exercises decrease atelectasis to a certain degree, not completely eliminating it, but these

exercises can be performed without the use of an incentive spirometer. (Westwood 341). The

incentive spirometer has no benefit over the other exercises.

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Now that the evidence is synthesized, it is clear that incentive spirometry on its own is

not effective in preventing pulmonary complications in hospitalized patients. In practice,

incentive spirometers are still being utilized very frequently despite the absence of clinical

evidence supporting the use of it. So to adapt the findings from this PICOT question for

practice, it is best to not use incentive spirometry alone as a routine regimen for preventing

postoperative pulmonary complications. Evidence does not support its use alone, only in adjunct

to other therapies and modalities. It is recommended that incentive spirometry be used with

deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to pre-

vent postoperative pulmonary complications. It is suggested that deep breathing exercises pro-

vide the same benefit as incentive spirometry in the preoperative and postoperative setting to

prevent post- operative complications. (Restrepo 1603). Eventually, there will be more

evidence out there to further investigate if incentive spirometers should be used at all in practice,

but in the meantime, the focus should be on maximizing breathing efforts through deep breathing

exercises, early ambulation, and coughing on a frequent basis during hospital stays.
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References Cited

Overend, T. J., Anderson, C. M., Lucy, S. D., Bhatia, C., Jonsson, B. I., & Timmermans, C.

(2001). The Effect of Incentive Spirometry on Postoperative Pulmonary Complications. Chest,

120(3), 971-978

Restrepo, R. D., Wettstein, R., Wittnebel, L., & Tracy, M. (2011). Incentive spirometry: 2011.

Respiratory Care, 56(10), 1600-1604. doi:10.4187/respcare.01471

Westwood, K., Griffin, M., Roberts, K., Williams, M., Yoong, K., & Digger, T. (2007).

Incentive spirometry decreases respiratory complications following major abdominal surgery.

Surgeon (Edinburgh University Press), 5(6), 339-342.