Thursday, May 25, 2017

Are incentive spirometers useless?

Has this ever happened to you? You walk into a patient's room on postoperative day 1 and find the incentive spirometer still in its plastic wrap. And it's on a windowsill 10 feet from the patient's bed.

Here's another question. Does it matter?

A friend just had a 4-vessel CABG at a major academic center. Despite a lack of evidence that incentive spirometers are effective, he was told to use one in the hospital and to use it hourly at home which he has faithfully done.

That’s right. The effectiveness of incentive spirometry in postoperative cardiac and abdominal surgery patients has never been proven.

Three Cochrane Reviews (2007, 2012, 2014) have been done. In the 2014 review analyzing 12 studies with 1834 subjects who underwent abdominal surgery, the authors noted problems with study methodologies and lack of data on compliance with the use of spirometers. For preventing pulmonary complications, spirometry was not superior to deep breathing exercises or no respiratory intervention at all.

That review concluded “There is low quality evidence regarding the lack of effectiveness of incentive spirometry for prevention of postoperative pulmonary complications in patients after upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field.”

A Cochrane Review of incentive spirometry use after coronary artery bypass grafting found similar results. “There was no evidence of a difference between groups in the incidence of any pulmonary complications and functional capacity between treatment with incentive spirometry and treatment with physical therapy, positive pressure breathing techniques (including continuous positive airway pressure, bilevel positive airway pressure and intermittent positive pressure breathing, active cycle of breathing techniques, or preoperative patient education). Patients treated with incentive spirometry had worse pulmonary function and arterial oxygenation compared with positive pressure breathing.”

Again due to problems with methodology, the review’s authors called for more studies of appropriate power.

Compliance with incentive spirometry is a big issue. A 2016 review in the Canadian Journal of Respiratory Therapy found many studies failed to report how compliance was assessed, and the prescription for incentive spirometer use varied widely.

A 2017 randomized trial involving 224 laparoscopic bariatric surgery patients compared incentive spirometry ordered 10 times per hour while the patient was awake to no spirometry. The two cohorts had similar baseline characteristics. No significant differences in postoperative hypoxemia [defined as an arterial oxygen saturation of less than 92%] or pulmonary complication rates were found between the two groups at any interval through 30 days postoperatively.

In the paper’s introduction, the authors point out that morbid obesity and laparoscopic foregut surgery both are known to result in high rates of postoperative pulmonary complications. At 6 hours postop, 11% of the patients in this study were hypoxemic.

Compliance with the device was not addressed in the trial, but a pilot study of 16 bariatric patients showed that on postop day 1, patients used incentive spirometers an average of 4 times per day. Use increased to 10 times per day on postop day 2 [far short of the prescribed 10 times per awake hour].

The average cost of an incentive spirometer is about $10. But the expense can add up if you consider that just five of the many operations after which the device is often used—cesarean section 1,300,000, joint replacement 1,000,000, hysterectomy 500,000, cholecystectomy 460,000, and coronary artery bypass graft 395,000—are performed over 3.6 million times per year.

That’s over $36 million spent for questionable value.


Christopher Johnson said...

I'm old enough to recall when all post-op patients got IPPB treatments QID. They were expensive and were never shown to work, either.

Skeptical Scalpel said...

I'm that old too. I spent the summer after my first year of med school working as a respiratory therapist. We gave IPPB treatments using Bird respirators--the little green box.

Anonymous said...

What is the downside to using an IS? The cost of $10 is nothing compared to other costs. If nothing else, it reminds the patient to breath deeply. It's hard to do a proper study to show a true benefit

Skeptical Scalpel said...

I said in the post it's $36 million for just 5 operations. It's hard to gather data on how many other abdominal and cardiac operations are done every year.

I have observed that incentive spirometers are used in other operations too--thoracic, orthopedic, gyn etc. Although they cost only $10 each, I would bet that at least $100 million/year are spent on them. To me, that's a lot of money for something that doesn't work.

Just a thought said...

I use it to get the patient involved in there care. I think deep breathing would be equal but this makes it a game for the patients. In a society that just wants a pill and nothing should be there responsibility, it gets them involved and ones that will do this are the ones out of bed sooner and home sooner.

Maybe just slightly better than placebo

Old FoolRN said...

It doesn't really matter - IPPB from flocks of Birds or floating ping pong balls in a transparent cylinder. Homo sapiens are attracted to the visual stimulation of these toys - maybe there is no science behind these treatments but they look cool and give nurses and respiratory therapists something to do. Sometimes just the patient interacting with the medical milieu is curative. It doesn't really matter what is done - paying money to educated people in uniforms or expensive suits is supposed to make people better. Empirical thinking at it's finest! To heck with science.

Skeptical Scalpel said...

Just, thanks for commenting. It's a pretty expensive placebo.

Old, yes it's a something to play with and if properly used, it engages the patient. To me, those are not good enough reasons to prescribe it.

William Reichert said...

The idea behind incentive spirometry was that it over comes
atelectasis which can lead to hypoxia or pneumonia.However, the best way to prevent atelectasis is to get the patient out of bed. and walking. This may require some encouragement by nursing but they are busy making love to the EHR so IPPB or Incentive spirometry can provides a substitute that, while ineffective,is billable . This has great appeal to those who are responsible
for the hospitals bottom line.

Skeptical Scalpel said...

Yes, Incentive spirometers are billable. Cost online--$10. Charge to patient--$250 [estimated].

Tracye said...

As an RT I can say they are ineffective mostly because the patient rarely uses it. There are better modalities now. Still, most surgeons will err on the side of prescribing Incentive Spirometry since one of the top reasons for readmission to the ICU is pulmonary complications.

Skeptical Scalpel said...

Tracye, I agree most patients don't use them, and research backs that up. I think it's easy to write for IS, docs think they are doing something, and as you can see by some previous comments, they are cheap -- until you do the math for the large number of operation done in the US.

RuggerMD said...

I have to completely disagree. In my trauma world of broken ribs and pain with each breath, IMO, incentive spirometry not only aids in deep breathing, but gives the patient a goal to achieve. Furthermore, I use it not only for treatment, but for assessing daily if a patient is improving their inspiratory volume or going backwards or stagnant. This also allows me to triage patient's to the proper floor, whether ICU, IMU or ward and alerts RT to the need to work with the patients to get their breathing better. All of that keeps patients out of trouble. Recognizing worsening pulm function is important after all. You will also be surprised how the volume goes up once you have good pain control, so I also use IS as an indicator for pain control.
I do agree for routine abdominal surgeries, it may not be very useful.
However, I do not see the study in my subset of patients. I guess that could be my next project.

Skeptical Scalpel said...

I appreciate your point of view. I hope you can do a study and show us that IS works for you in that setting. I would be happy to read it and blog about it.

Anonymous said...

so do you order this? curious!

Skeptical Scalpel said...

I am retired so I don't order anything. If I was still practicing, I would not order an incentive spirometer. I would tell the patient to cough and deep breathe every 30 minutes while awake and ask the nurse to leave her computer occasionally to make sure the patient was doing so.

Anonymous said...

Wow, leave their computer. Documentation is required by nurses. They work very hard. That is good that you are retired. Nurses are under the gun all the time in not only caring for their patients but documenting their care. They do bedside care as well. I see many doctors rush in and out and by the way...behind a computer mostly.

Skeptical Scalpel said...

Funny, when I talk to nurses, all they do is complain about all the useless computer charting they are required to do. I'm not saying it's their fault, but it is a fact. The electronic medical record has caused both doctors and nurses to be slaves to the computer.

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