A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer

The purpose of incentive spirometry is to facilitate a sustained slow deep breath. Incentive spirometry is designed to mimic natural sighing by encouraging patients to take slow, deep breaths. Incentive spirometry is performed using devices which provide visual cues to the patients that the desired flow or volume has been achieved. The basis of incentive spirometry involves having the patient take a sustained, maximal inspiration (SMI). An SMI is a slow, deep inspiration from the Functional Residual Capacity up to the total lung capacity, followed by ≥5 seconds breath hold.

An incentive spirometer is a medical device that facilitate SMI with incorporated visual indicators of performance (inspiratory effort) in order to aid the therapist in coaching the patient to optimal performance and likewise patients uses this visual feedback to monitor their own efforts. The device gives the individual visual feedback regarding flow and volume and also prevent and reverse atelectasis when used appropriately and regularly. The visual dimension of the therapy serves as a motivation or goal for the patient to try to meet by repeating the maximal effort frequently.

There are typically two types of incentive spirometer, namely:

• Flow-oriented incentive spirometer (Triflow Device) - Has three chambers with one ball in each chamber. Capacity up to 1200ml.
• Volume-oriented incentive spirometer - Has one-way valve with capacity up to 4000ml. Current evidence tells us that using this type of spirometer requires lesser work of breathing and improves diaphragmatic function. Using this device improves pulmonary function better compared to Triflow.

Image: Overview of the respiratory system

Guidelines on appropriate use[edit | edit source]

1. Therapist demonstrates using a separate device and provides an information sheet regarding technique, prescription of use and cleaning advice based on manufacturers instructions.
2. Patient should be in a relaxed position suitable for deep breathing (e.g. sitting upright in a chair or side lying if extra volume is required in one lung due to ventilation perfusion matching).
3. Patient creates a tight seal around the mouthpiece and inhales deeply and slowly. The patient watches the flow meter for visual feedback. If possible the patient sustains the inhalation to create an end-inspiratory hold. Ideally, the inhalation is sustained for 4-5 seconds.
4. Patient relaxes seal around the mouthpiece and exhales; normal breathing is resumed with relaxed shoulder girdle.
   

Further pointers:

• Advise patient to take approximately ten incentive spirometry breaths per waking hour (use clinical reasoning to prescribe using Frequency, Intensity, Time and Type principles).
• Patients with an oxygen requirement can use the device with a nasal cannula or a device, which entrains oxygen.
• Deep breathing offers a similar effect. However, using an incentive device as feedback may create greater inhaled volumes, greater control of flow and more motivation to participate in therapy.
  

The video below explains more on the use of the incentive spirometer

The indications are:

• Pre-operative screening of patients at risk of postoperative complications to obtain a baseline of their inspiratory flow and volume
• Presence of pulmonary atelectasis
• Conditions predisposing to atelectasis such as:
  1. Abdominal or thoracic surgery
  2. Prolonged bed rest
  3. Surgery in patients with COPD
  4. Presence thoracic or Abdominal binders
  5. Lack of pain control

The Contra-indications are:

• Patients who cannot use the device appropriately or require supervision at all times
• Patients who are noncompliant or do not understand or demonstrate proper use of the device
• Very young patients or paediatrics with developmental delay
• Hyperventilation
• Hypoxaemia secondary to interruption of oxygen therapy
• Fatigue
• Patients unable to take deep breathe effectively due to pain, diaphragmatic dysfunction, or opiate analgesia.
• Patients who are heavily sedated or comatose
• The device is not suitable for people with severe dyspnoea.

Certain Precautions need to be taken when using the spirometer:

• The technique is inappropriate as the sole treatment for major lung collapse or consolidation.
• Hyperventilation may result from improper technique.
• There is potential for barotrauma in emphysematous lungs.
• Discomfort may occur secondary to uncontrolled pain.
• Development of bronchospasm may occur in susceptible patients. Close monitoring of patients with hyper-reactive airways should be maintained. 

A moderate body of evidence has examined the use of incentive spirometry and it's effectiveness following a variety of surgeries and reducing the risk of post-operative complications. It's effectiveness has been varied but all systematic reviews highlight flaws in methodology of studies carried out.

A systematic review carried out by Overend et al., 2001 reviewed the evidence examining the use of incentive spirometry for the prevention of postoperative pulmonary complications. Due to flaws in study methodology they concluded that at present, the evidence does not support the use of incentive spirometry for decreasing the incidence of post operative pulmonary complications following cardiac or upper abdominal surgery.

A recent systematic review completed in 2016 examined the evidence regarding patient compliance with incentive spirometry after cardiac, thoracic and abdominal surgery. They concluded that there is a scarcity and inconsistency of evidence regarding incentive spirometry compliance. They identified the importance of reporting this outcome measure to examine the effectiveness of this treatment adjunct.

A randomised controlled trial was conducted to compare pre-operative and post-operative effects of Diaphragmatic Breathing Exercise (DBE), Flow-incentive Spirometer and Volume-incentive spirometer on pulmonary function in CAGB patients. The study concluded that Volume-incentive spirometer has the greater effect among the other two.

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