Is incentive spirometry effective following thoracic surgery? Free

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether incentive spirometry is a useful intervention for patients after thoracic surgery. Altogether 255 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that incentive spirometry is a relatively good measure of lung function and may be used to assess respiratory recovery in the days after thoracic surgery. Physiotherapy either with or without incentive spirometry reduces the incidence of postoperative complications and improves lung function but there is currently no evidence that incentive spirometry in itself could either replace or significantly augment the work of the physiotherapists. Clinicians should be aware that while incentive spirometry can provide an assessment of lung recovery, well-organised and regular physiotherapy remains the most effective mechanism to augment their patient's recovery and avoid postoperative complications.

1. Introduction

A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

2. Three-part question

In [patients undergoing lobectomy or pneumonectomy] is the use of [incentive spirometry] of benefit in preserving [postoperative pulmonary function and preventing pulmonary complications]?

3. Clinical scenario

A 73-year-old patient with a history of COPD and diabetes, two days after a right upper lobectomy for lung cancer, asks you why he has not got an incentive spirometer by his bed when the two patients opposite him both have them. You can't answer him and when you look more deeply into this find that administration of spirometers on your ward is sporadic. We decide to check the literature and decide who should get them.

4. Search strategy

Medline was searched from 1950 to October 2007, Embase was searched from 1980 to October 2007 and CINAHL was searched from 1982 to October 2007 all using the OVID interface.

Search term was: [incentive spirometry.mp]

The Cochrane Library was searched using the terms ‘incentive spirometry’ and ‘postoperative physiotherapy’. The Chartered Society of Physiotherapy Resource Centre was also searched and a hand search was used to follow-up references from the retrieved studies.

5. Search outcome

One hundred and six studies were found in Medline, 99 in Embase and 42 in CINAHL. Eight references were found in the Cochrane Library and one paper in the physiotherapy resource centre. Seven papers were selected as giving the best evidence on the topic. These are presented in Table 1 .

6. Results

Gosselink et al. [2] performed a randomised controlled trial on subjects following lung (n=40) and oesophageal (n=27) surgery. Groups were either treated with postoperative physiotherapy (PT) comprising deep breathing exercises, huff and cough, or incentive spirometry (IS). Outcomes were assessed for FEV₁, length of stay (LOS) and rate of postoperative pulmonary complication (PPC) (defined by raised white cell count, increased temperature and chest X-ray changes). No differences in the postoperative restoration of pulmonary function (% recovery of FEV₁ PT vs. PT+IS 88±44% vs. 72±17%) or pulmonary complications (PT 12.5% and PT+IS 11%) were demonstrated.

Vilaplana et al. [3] performed a small (n=37) randomised comparative physiotherapy trial concerned with rate of PPC. They examined subjects having undergone thoracotomy for oesophageal (n=16) or pulmonary surgery (n=21). The groups received incentive spirometry with chest physiotherapy, or chest physiotherapy alone. The results found that incentive spirometry was not associated with preservation of FEV₁ after 48 h of treatment, nor was it associated with improved postoperative gas exchange.

Weiner et al. [4] performed a randomised controlled trial concerning the effect of incentive spirometry and inspiratory muscle training on predicted postoperative pulmonary function following lung resection. Thirty-two COPD patients were randomised; one group received physiotherapy input consisting of incentive spirometry with inspiratory muscle training two weeks preoperatively and for three months postoperatively, the other group received no specific training. The treatment group was found to have better predicted postoperative (ppo) FEV₁ than the control group (lobectomy +570 vs. –70, pneumonectomy +680 vs. –110 at three months). This paper correctly uses ppoFEV₁ to take into account the number of segments resected. However, it is uncertain in this study how much of this improvement in ppoFEV₁ can be attributed to the volume effect of IS or the ‘loading’ effect of inspiratory muscle training. This paper was not primarily concerned with the use of these treatments for preventing PPC but the authors did note that there were two cases of postoperative pneumonia in each group.

The most recent study by Varela et al. [5] used a cross-sectional design with historical controls (non-randomised) to evaluate the cost-effectiveness of chest physiotherapy following lobectomy. One hundred and nineteen patients received intensive chest physiotherapy, specifically receiving instruction in deep breathing exercises and cough, they were also exercised using a static bicycle and treadmill. They were compared with a group of 520 similar patients previously treated at the same hospital who had received routine nursing care and incentive spirometry. In this study, incentive spirometry was not compared as a physiotherapy treatment, but was used independently by patients instead of physiotherapy. Selected outcomes included 30 days mortality, respiratory complications (atelectasis and pneumonia), and LOS. The prevalence of atelectasis and LOS were decreased in the physiotherapy group 2% vs. 7.7% and 5.7 vs. 8.33 days, respectively. The analysis showed that overall cost for hospital treatment in this group was lower. However, ppoFEV₁ was no different (68.8 vs. 69.1) in either group though timing of this measurement is not stipulated.

In the cardiac surgical literature, Freitas et al. [6] performed a Cochrane review of incentive spirometry for patients after CABG. They only found four RCTs and found no improvements in reducing the incidence of pulmonary complications in these trials.

Overend et al. [7] also performed a systematic review after all types of surgery, finding 11 good quality papers, 10 of which showed no benefit.

Bastin et al. [8] showed that incentive spirometry correlated reasonably well with vital capacity and inspiratory reserve volume and proposed that it was a fairly good marker of lung function after lobectomy.

7. Clinical bottom line

Incentive spirometry is a relatively good measure of lung function and may be used to assess respiratory recovery in the days after thoracic surgery. Physiotherapy either with or without incentive spirometry reduces the incidence of postoperative complications and improves lung function but there is currently no evidence that incentive spirometry in itself could either replace or significantly augment the work of the physiotherapists. Clinicians should be aware that while incentive spirometry can provide an assessment of lung recovery, well-organised and regular physiotherapy remains the most effective mechanism to augment their patient's recovery and avoid postoperative complications.

References