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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]?

Clinical Scenario

A 73 year old patient with a history of COPD and diabetes, 2 days after a right upper lobectomy for lung cancer asks you why he has not got an incentive spirometer by his bed when the 2 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.

Search Strategy

MEDLINE was searched from 1950 to Oct 2007 , EMBASE was searched from 1980 to Oct 2007 and CINAHL was searched from 1982 to Oct 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.

Search Outcome

106 studies were found in MEDLINE and 99 in EMBASE and 42 in CINAHL. 8 references were found in the Cochrane Library and one paper in the physiotherapy resource centre. 7 papers were selected as giving the best evidence on the topic. These are presented in the Table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gosselink et al, 2000, Belgium	67 thoracic surgery patients – 40 lung/27 oesophageal resection comparison of postoperative chest PT vs postoperative chest PT vs IS	PRCT (level 1b)	FEV recovery	Physiotherapy 88±44. PT and incentive spirometry 72±17 (no significant difference)	The rate of PPC as noted by the authors is relatively low hence this study is underpowered to detect differences in this complication. The authors did not consider the number of segments resected in determining their covery of FEV. The type of inclusion was not specified within the paper
			PPC	Physiotherapy 4/35. Physio and incentive spirometry 4/32
			LOS	Physiotherapy 15±7 . Physio and incentive spirometry 14±8
Vilaplana et al, 1991, Spain	37 thoracic surgery patients - 21 lung and 16 oesophageal surgery. Comparison of postoperative chest PT vs chest PT with IS	PRCT (level 1b)	PPC	Physiotherapy 4/19. Physio and incentive spirometry 6/18.	The authors did not consider the number of segments resected in determining early preservation of FEV
			Drop in FEV	PT vs PT+IS oesophageal 49 vs. 51 lung 45 vs. 50
			LOS	Physiotherapy 30.5±16. Incentive spirometry and physio 23.8±11
Weiner et al, 1997, Israel	32 COPD lung resection patients - lobectomy/pneumonectomy. Comparison of IS and inspiratory muscle training pre and postopertive with no treatment group	PRCT (level 1b)	ppoFEV	IS and inspiratory muscle training vs. no treatment PPC 2/17 vs. 2/15
			Value above ppoFEV	IS and inspiratory muscle training vs. no treatment. Lobectomy +570 vs. –70 Pneumonectomy +680 vs. –110 at 3 months
Varela et al, 2005, Spain	639 lobectomy patients (muscle sparing thoracotomy or video-assisted thoracoscopy). Compared intensive PT vs IS along (control)	Cohort study (level 2b)	Atelectasis	Intensive physiotherapy 2%. Incentive physiotherapy 7.7%. OR 0.2 CI 0.05–0.86
			LOS	Intensive physiotherapy 5.73 (2–22) days. Incentive spirometry 8.33 (3–40) days P<0.001
			ppoFEV	Intensive physiotherapy 68.8 (15.72). Incentive spirometry 69.14 (16.97)% (S.D.) P=0.47
Freitas et al, 2007, Brazil	Selection criteria: Randomised controlled trials comparing incentive spirometry with any type of prophylactic physiotherapy for prevention of postoperative pulmonary complications in adults undergoing CABG	Systematic review of RCT's (level 1a)	Number of studies found	4 RCTS found with 443 participants	Only 4 studies finally selected for inclusion in the review The intervention in these 4 studies varied from incentive spirometry vs controls to spirometry in addition to postoperative physiotherapy or CPAP
			Conclusion	Individual small trials suggest that there is no evidence of benefit from incentive spirometry in reducing pulmonary complications, including atelectasis, pneumonia, number of days in hospital and in decreasing the negative effects on pulmonary function in patients undergoing CABG
Overend et al, 2001, Canada	A review of 46 studies looking at incentive spirometry to prevent postoperative pulmonary complications	Systematic review (level 1a)	Study review	35 out of the 46 studies were rejected due to flaws in their methodology. 10 of the remaining 11 showed no benefit following cardiac or abdominal surgery. 1 study showed that either incentive spirometry or deep breathing or positive pressure breathing equally reduced pulmonary complications.	No papers in thoracic surgery reviewed
Bastin et al, 1997, Belgium	19 patients undergoing lobectomy with an FEV1/FVC <75%. Measured correlation with incentive spirometry and a range of pulmonary function tests		Correlation coefficient	Incentive spirometry vs vital capacity R=0.667 and 0.870 (good). Incentive spirometry vs.inspiratory reserve volume R=0.680 and 0.895 (good) IC vs. expiratory reserve volume R=below 0.340 (poor) IC vs. FRC R=below 0.470 (poor)

Comment(s)

Gosselink 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 performed a small(n=37) randomized 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 hours of treatment, nor was it associated with improved postoperative gas exchange. Weiner performed a randomized controlled trial concerning the effect of incentive spirometry and inspiratory muscle training on predicted postoperative pulmonary function following lung resection. 32 COPD patients were randomized; 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 post-operative(ppo) FEV1 than the control group (lobectomy +570 vs -70, Pneumonectomy +680 vs -110 at 3 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 2 cases of postoperative pneumonia in each group.

The most recent study by Varela used a cross-sectional design with historical controls (non-randomized) to evaluate the cost-effectiveness of chest physiotherapy following lobectomy. 119 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 day 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 performed a Cochrane review of incentive spirometry for patients after CABG. They only found 4 RCTs and found no improvements in reducing the incidence of pulmonary complications in these trials. Overend also performed a systematic review after all types of surgery, finding 11 good quality papers, 10 of which showed no benefit Bastin 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.

Editor Comment

PPC= postoperative pulmonary complication, LOS= length of hospital stay IS= incentive spirometry, PT= physiotherapy

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 post-operative 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 post-operative complications.

References

1. Gosselink R, Schrever K, Cops P, Witvrouwen H, De LP, Troosters T, Lerut A, Deneffe G, Decramer M. Incentive spirometry does not enhance recovery after thoracic surgery. Critical Care Medicine 2000;28(3):679-83.
2. Vilaplana J, Sabate A, Gasolibe V, Villalonga R. Inefficiency of incentive spirometry as coadjuvant of conventional chest physiotherapy for the prevention of respiratory complications after chest and oesophagus surgery. Revista Espanola de Anestesiologia y Reanimacion 1991;37:321-5.
3. Weiner P, Man A, Weiner M, Rabner M, Waizman J, Magadle R, Zamir D, Greiff Y. The effect of incentive spirometry and inspiratory muscle training on pulmonary function after lung resection. Journal of Thoracic & Cardiovascular Surgery 1997:113(3):552-7.
4. Varela G, Ballesteros E, Jimenez MF, Novoa N, Aranda JL. Cost-effectiveness analysis of prophylactic respiratory physiotherapy in pulmonary lobectomy. European Journal of Cardio-Thoracic Surgery 2006:29(2):216-20.
5. Freitas ER, Soares BG, Cardoso JR, Atallah AN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database of Systematic Reviews (3):2007:CD004466.
6. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. Chest 2001:120(3):971-8.
7. Bastin R, Moraine JJ, Bardocsky G, Kahn RJ, Melot C. Incentive spirometry performance. A reliable indicator of pulmonary function in the early postoperative period after lobectomy? Chest 1997:111(3):559-63.