Original Article

Incentive spirometry K. Westwood1

fn1
M. Grif
K. Roberts2
M. Williams1

decreases respiratory K. Yoong2

T. Diggerr3
Departments of Physiotherapy1, Upper GI
Surgeryy2, and Critical Care3, Russells Hall
Hospital, Dudley, West Midlands, DY1 2HQ

complications following Correspondence to: Keith Roberts,

77 Three Acres Lane, Dickens Heath,
Solihull, B90 1NZ, UK
Tel: +44 (0)7801 658505

major abdominal surgery Email: dr_keith@hotmail.com

Pulmonary complications are the leading cause of morbidity and mortality following major abdominal
surgery. Chest physiotherapy aims to decrease the likelihood of these complications and hasten
recovery. Exercises aimed at maximising inspiratory effort are the most benecial
 for the patients. The
incentive spirometer is a handheld device that patients use to achieve effective inspiration. In a non-
randomised pilot study of 263 patients we have found that the addition of the incentive spirometer, as
part of an intensive post-operative physiotherapy programme, decreased the occurrence of pulmonary
complications (6 vs 17%, p=0.01) and length of stay on the surgical high dependency unit (3.1 vs 4 days
p=0.03). The two groups were comparable when age, sex, smoking history, the need for emergency
surgery and post-operative analgesia were compared.
Keywords: Incentive spirometer, post-operative physiotherapy, post-operative pulmonary complication
Surgeon, 1 December 2007 339-42

INTRODUCTION
Following major abdominal surgery, pul-
monary complications are the leading cause
of post-operative morbidity and mortality
affecting 25–50% of patients.1,2 In addition,
these complications can lead to increased
patient discomfort, increased consumption of
resources, longer length of stay and, thus, over-
all increased health care costs.3 Chest physi-
otherapy is widely applied by surgical units in
an attempt to reduce PPCs. However, evidence
for its ef
fcacy is relatively limited and studies
comparing different physiotherapy modalities
are limited.
Patients who have abdominal or tho-
racic incisions experience wound pain and
diaphragmatic dysfunction, which compro-
mise effective respiration. Atelectasis is the
pathological process of alveolar collapse. It
begins during general anaesthesia and can be
promoted in the post-operative period in
patients who have compromised ability to
achieve an effective tidal volume. Pain,
diaphragmatic dysfunction and opiate anal-
gesia are the most common mechanisms of
reduced inspiration. These decreased tidal
volumes reduce the distending forces within
the lung and permit alveolar collapse.3 This
creates a restrictive lung defect, causing
reduced lung compliance, compromised muco-
ciliary clearance, depletion of surfactant and
pre-disposition to infection.3,4
Post-operative respiratory physiotherapy
aims to promote maximal inspiration in order
to expand collapsed alveoli and prevent
further atelectasis.5 An incentive spirometer is
a device that is designed to achieve and sustain
this maximal inspiration. It is simple to use and
provides the patient with visual feedback on
ow and volume. Its use results in a prolonged
phase of effective inspiration, more control-
led ow and greater enthusiasm to practice.4
There are no known side effects with the use
of incentive spirometers; they are inexpensive
and patients do not require supervision once
trained in their use. Following the acquisition

© 2007 Surgeon 5; 6: 339-42 The Royal Colleges of Surgeons of Edinburgh and Ireland 339
 of knowledge and experience of the device from other
hospitals, we introduced the incentive spirometer to our
general surgical unit. We present our experience before Control IS p - value
and after introduction of the spirometer and its effect Demographics Age (average) 68 67
upon PPCs, physiotherapy resources and hospital length
Male/Female 63/48 63/54
of stay.
Respiratory 11 23 0.025
METHODS disease
This was a prospective observational study over eight months Smoking status Non 43 42
(July 2004 - February 2005) of all patients attending the surgi- (%)
Smoker
cal high dependency unit (SHDU) directly following surgery 24 21
where the abdomen or chest was opened. If the surgery per- Ex
30 32
formed was not planned as an elective procedure, the operation
was regarded as an emergency. Sub speciality Colorectal 63 69
For the rst four months the patients received standard chest of surgery (%)
Upper GI 16 17
physiotherapy. This consisted of ve deep breaths, each with an
inspiratory hold and sniff and followed by a supported cough, Other laparotomy 11 5
taught by the physiotherapist: patients were then advised to AAA 8 2 0.025
continue this regimen every half an hour. Patients were seen Ivor Lewis 2 7
daily, however, those with poor inspiratory effort, retained Oesophagectomy
secretions or decreased compliance with treatment were seen
Emergency 28 30 0.1
a minimum of twice a day. This treatment continued when the
surgery
patient was transferred to the ward. There was a 24-hour on-
call emergency physiotherapy service available. ASA 2.4 2.4
During the nal four months all patients received standard Main method of Epidural 61 63
chest physiotherapy but without inspiratory hold and sniff; deep post-operative
PCA 15 19
breaths were performed via an incentive spirometer in order to analgesia
achieve sustained maximal inspirations (SMIs). Education on Morphine infusion 8 5
the use of the device was given and patients were instructed Indeterminate 15 13
to take 
ve SMIs every half an hour.
PPC (%) 17 6 0.01
We recorded length of stay on SHDU and in hospital to dis-
charge, PPCs, time spent by physiotherapy staff with each patient Length of stay SHDU 4 3.1 0.034
and on-call physiotherapy contacts. PPCs were dened  as the (days)
Ward 15.2 12.4 0.18
presence of clinical features consistent with collapse or consoli-
dation, plus an otherwise unexplained temperature above 38ºC, Physiotherapy Contacts per pt 9.4 8.2 0.18
and either positive 
ndings on chest radiography or evidence of workload
Time per pt (total, 4 3.5 0.2
infection from sputum microbiology.5 This de nition of PPCs is in hours)
further supported by previously published work.6,7 Physiotherapy Excluded pts Return to theatre 2 4
time was determined by utilising an existing and ongoing Trust

audit in which contact with a patient yields a score that reects Died 10 12
both time spent and by what grade of physiotherapist, thus Transfer to ITU 0 5
enabling a cost per contact to be calculated according to current
physiotherapy salary scales. PPC: post-operative pulmonary complication; PCA: patient controlled anal-
Patients with pre-existing respiratory disease and/or gesia; AAA: abdominal aortic aneurysm; ASA: American Society of Anesthe-
sia score; SHDU: surgical high dependency unit; ITU: intensive therapy unit
smoking history were identi ed. Respiratory disease was
classied
 as a patient with a diagnosis consistent with COPD
and/or asthma and requiring regular medication. Ex-smokers
were subjects who had stopped smoking more than one month
prior to surgery. If they had quit within the month they were RESULTS
included as a ‘smoker’. See Table 1 for a summary of the group demographics and
The following patients were excluded: those who returned results. There were a total of 263 patients; 32 were excluded
to theatre in the immediate post-operative period, as their – 12 in the no incentive spirometry group (no IS), leaving 111,
prolonged length of stay would be associated with abdominal and 20 in the incentive spirometry (IS) group, leaving 117.
rather than respiratory pathology; those who were admitted to Table 1 shows details of excluded subjects.
ITU for ventilation post-operatively, as these patients would There was no signi cant difference in the sub-speciality of
be unable to comply with chest physiotherapy; and those who the surgery performed amongst the largest groups (Table 1).
died on return from theatre. There were fewer patients undergoing Ivor Lewis oesophagec-
There were no changes in consultant anaesthetic, tomy in the no IS group (2 vs 7%, p=0.1) but more undergoing
consultant surgical, nursing or physiotherapy staff during the repair of abdominal aortic aneurysm (8 vs 2%, p=0.025).
study period. No protocols were introduced or changed that The average age was 68 (no IS) vs 67 (IS). There were
would affect patient care, length of stay or physiotherapy more patients with respiratory disease in the IS group (23% vs
contacts with patients. 11%, p=0.025). Smoking habits were comparable with no sig-

340 The Royal Colleges of Surgeons of Edinburgh and Ireland © 2007 Surgeon 5; 6: 339-42
ni
cant difference: smokers (no IS 24%, IS 21%), ex-smokers
(no IS 30%, IS 32%) and non-smokers (no IS 43%, IS 42%);
not known (no IS 3%, IS 6%).
The main modality of post-operative analgesia was com-
parable; epidural (no IS 61%, IS 63%), patient controlled
analgesia (no IS 15%, IS 19%) and morphine infusion (no
IS 8%, IS 5%). In some cases it was not possible to clearly
identify a main modality of analgesia (no IS 15%, IS 13%).
The average American Society of Anesthesia (ASA) score was
2.4 and the median score was 2 for both groups. There was no
signicant
 difference in the proportion of emergency patients
in either group (no IS 28% vs IS 30% p=1). Seventeen per cent
of patients in the no IS group developed PPCs vs 6% in the IS
group (p=0.01).
The average length of stay on SHDU was 4 days in the group
without IS and 3.1 days in the IS group (p=0.034); the median
length of stay was 3 vs 2 days. Total hospital length of stay
was 15.2 days in the no IS group vs 12.4 days in the IS group
(p=0.18); the median stay was 11 days in both groups.
Physiotherapists spent less time with the IS group, 3.5 hours
vs. 4.0 hours (p=0.2). The average number of contacts physio-
therapists had with each patient was 8.2 in the IS group vs 9.4 in
the no IS group (p=0.18). Physiotherapists were requested to see
patients as emergency contacts less often in the IS group (0.9 vs.
1.1); however, this failed to achieve statistical signi
cance.
DISCUSSION
Post-operative respiratory physiotherapy attempts to achieve
early re-expansion of collapsed alveoli and prevention of further
atelectasis in order to avoid subsequent infection. In patients
with decreased tidal volumes and functional residual capac-
ity, deep and prolonged inspiratory efforts promote reversal
of atelectasis and enhance surfactant replenishment.7 Thus,
optimal techniques of respiratory physiotherapy focus on pro-
moting maximal inspiratory effort.5 It has been demonstrated
that patients who achieve 80% of their pre-operative inspiratory
volume have fewer post-operative pulmonary complications,
compared with those who achieve a lower percentage.8
The incentive spirometer promotes this effective inspiration
by visual feedback and encourages enthusiasm amongst patients
who use it.4 There is clear evidence that maximal inspiratory
exercises decrease post-operative atelectasis (detected via a
radiograph). In a study of 343 patients undergoing open chole-
cystectomy, the incidence of atelectasis in the control group was
42% vs 27% of those receiving physiotherapy focusing upon
inspiratory exercises. The rate of atelectasis fell to 12% when
the patients had received additional pre-operative instruction.9
What is less clear is whether any of the modalities or exercises
aimed at achieving maximal inspiration have any benets  over
one another. Incentive spirometry has several potential advan-
tages: effective inspiratory efforts are optimised 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-oper-
ative physiotherapy techniques or assisted lung expansion.
However, this evidence is generally of low quality. A systematic
review published in 2001 identi ed 46 studies for analysis.10
Thirty-ve
 were rejected due to awed methodology leaving
11 for evaluation. Of these, seven studies had subject popula-
© 2007 Surgeon 5; 6: 339-42
tions of less than 50 and six involved patients undergoing car-
diac surgery. Only two studies were conducted upon patients
following abdominal surgery and involved greater numbers
of patients (n=65 and n=172), but both compared IS (patient-
generated tidal volumes) with methods of administering
positive pressure; i.e. continuous positive airways pressure and
intermittent positive pressure breathing (machine-generated
tidal volumes).11,12 These methods are not routinely used follow-
ing major abdominal surgery.
The study was designed as a before and after observational
study. The primary outcome measure was the rate of PPCs. The
interpretation of PPC is open to observer bias but strict criteria
were applied and in keeping with previously published work.5,6,7
We recognise that other objective measurements, such as peak
expiratory ow, FVC and FEV1, could have been employed
to further investigate recovery of respiratory function in the
two groups. Such measurements have been included in our
subsequent study.
The secondary outcome measure of length of stay was
chosen for two reasons;  rstly, length of stay should be
proportional to the rate of post-operative complications, of
which PPCs are the most frequent.2 Thus, a shorter length
of stay supports an observation of a decreased rate of PPCs,
knowing that the interpretation of PPC is open to observer bias.
The decision to discharge the patients to the ward from SHDU
and from the ward home was made by the surgical teams, who
were blinded to the study. The rate of PPCS was recorded by
two physiotherapy staff (KW and MG). Secondly, length of
stay has nancial and resource implications.
The most noteworthy difference when comparing excluded
patients in the two groups was that  ve patients in the IS group
required transfer to ITU for ventilation in the immediate post-
operative period. However, closer examination of the reasons
for transfer revealed that no patient required ventilation for
respiratory failure secondary to lung infection, but rather for
reasons such as cardiac complications and sepsis of presumed
abdominal origin.
Following the results of this observational study we now
have funding for a randomised controlled trial and data
collection is under way. We expect to complete this study in
late 2007. We believe that a large randomised controlled trial
identifying the effect of IS is warranted for two main reasons:
rstly, the majority of previously published work is of poor

scientic
 quality (a combination of poor study design, inap-
propriate comparison of different physiotherapy techniques
and low numbers of subjects included) and secondly, stand-
ard physiotherapy given to patients who have undergone
major abdominal surgery in the UK is now different from that
described in the previous articles. This last point is important
and has been overlooked in the latest systematic review.10
Previously published studies have tended to give physiother-
apy on a less frequent basis than is routine in our Trust, and
as far as we know, in other Trusts at the present time. Sub-
jects in Hall’s et al. control group were provided with one
episode of physiotherapy following surgery and in the treat-
ment group IS was used as the sole physiotherapy modali-
ty.5 In a study by Schweiger et al, IS was the only method
of physiotherapy given to the treatment group; the control
group received no physiotherapy.13 In the largest study, Celli
et al. identied that intermittent positive pressure breath-
ing, deep breathing exercises and IS were all better than no
The Royal Colleges of Surgeons of Edinburgh and Ireland 341
 therapy but one treatment was not superior to another.14 In this
study, a single exercise was used as the sole treatment. Our aim,
therefore, was to conduct a study identifying the impact of
adding incentive spirometry to an existing and intensive post-
operative physiotherapy programme.

CONCLUSION
This observational study has demonstrated a decreased
incidence of PPC when IS is added to an intensive programme
of post-operative physiotherapy. Associated with this is a
shorter length of stay on SHDU, less physiotherapy time with
each patient and fewer on-call physiotherapy contacts. This is
despite the IS group having a signicantly
 greater number of
patients with pre-existing lung disease. Although this study
evaluates a change in practice over time, analysis of the two
groups demonstrates little in the variables most likely to affect
PPC. There was no signi cant difference between the two
groups when independently assessing age, smoking history,
method of post-operative analgesia, ASA grade and nature of
surgery (emergency/elective).

Copyright © 26 June 2007

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342 The Royal Colleges of Surgeons of Edinburgh and Ireland © 2007 Surgeon 5; 6: 339-42