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Does the use of incentive spirometry in hospitalized patients decrease the risk of pulmonary
Sarah Perfetuo
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
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
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
RUNNING HEAD: PICOT Paper 3
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
searching using EBSCO host, the key words I inputted were incentive spirometry,
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
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
These studies were obtained through primary searches of computerized databases, using key
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 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
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
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
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
evidence is generally of low quality. (Westwood 341). Across the board, evidence showing
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
Now that the evidence is synthesized, it is clear that incentive spirometry on its own is
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.
120(3), 971-978
Restrepo, R. D., Wettstein, R., Wittnebel, L., & Tracy, M. (2011). Incentive spirometry: 2011.
Westwood, K., Griffin, M., Roberts, K., Williams, M., Yoong, K., & Digger, T. (2007).