Is Incentive Spirometry Superior to Standard Care in Postoperative Cardiac Surgery on Clinical Outcomes and Length of Hospital and Intensive Care Unit Stay? A Systematic Review with Meta-Analysis

Silva, Hiago Vinicius Costa; Lunardi, Adriana Claudia; Pinto, Ana Carolina Pereira Nunes; Macedo, Juliana Ribeiro Fonseca Franco de; Santos, Elinaldo da Conceição dos

doi:10.21470/1678-9741-2022-0319

Hiago Vinicius Costa Silva

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

final approval of the version to be published

Department of Biological and Health Sciences, Universidade Federal do Amapá, Macapá, Amapá, Brazil

Adriana Claudia Lunardi

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

drafting the work or revising it critically for important intellectual content

agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

final approval of the version to be published

Programa de Pós-Graduação Stricto Sensu em Fisioterapia, Universidade Cidade de São Paulo, São Paulo, São Paulo, Brazil

Department of Physical Therapy, Escola de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil

Ana Carolina Pereira Nunes Pinto

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

drafting the work or revising it critically for important intellectual content

agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

final approval of the version to be published

Department of Biological and Health Sciences, Universidade Federal do Amapá, Macapá, Amapá, Brazil

Department of Physical Therapy, University of Pittsburgh, Pennsylvania, United States of America

Juliana Ribeiro Fonseca Franco de Macedo

Drafting the work or revising it critically for important intellectual content

agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

final approval of the version to be published

Department of Health Sciences, Catholic University of Louvain, Brussels, Belgium

Elinaldo da Conceição dos Santos Correspondence Address: Elinaldo da Conceição dos Santos, https://orcid.org/0000-0002-4039-2980, Department of Biological and Health Sciences, Universidade Federal do Amapá, Rodovia Josmar Chaves Pinto, S/N, Jardim Marco Zero, Macapá, AP, Brazil, Zip Code: 68902-280, E-mail: drelinaldo@yahoo.com.br

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

drafting the work or revising it critically for important intellectual content

agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

final approval of the version to be published

Department of Biological and Health Sciences, Universidade Federal do Amapá, Macapá, Amapá, Brazil

Correspondence Address: Elinaldo da Conceição dos Santos, https://orcid.org/0000-0002-4039-2980, Department of Biological and Health Sciences, Universidade Federal do Amapá, Rodovia Josmar Chaves Pinto, S/N, Jardim Marco Zero, Macapá, AP, Brazil, Zip Code: 68902-280, E-mail: drelinaldo@yahoo.com.br

No conflict of interest.

Figures (7)
Tables (8)

Thumbnail

Fig. 1
Flow diagram of systematic review. CENTRAL=Cochrane Central Register of Controlled Trials; CINAHL®=Cumulative Index of Nursing and Allied Health; LILACS=Latin American and Caribbean Health Sciences Literature; PEDro=Physiotherapy Evidence Database; SciELO=Scientific Electronic Library Online.

Thumbnail

Fig. 2
Meta-analyses of the results for the primary outcomes of incentive spirometry vs. respiratory care. CI=confidence interval; PPC=postoperative pulmonary complications.

Thumbnail

Fig. 3
Meta-analyses of the results for the secondary outcomes of incentive spirometry vs. respiratory care. CI=confidence interval; FEV1=forced expiratory volume in one second; FVC=forced vital capacity; ICU=intensive care unit; LOS=length of stay; PaO₂=partial pressure of oxygen; PEF=peak of expiratory flow; SD=standard deviation; SO₂=oxygen saturation; VC=vital capacity.

Thumbnail

Fig. 4
Meta-analyses of the results for the primary outcomes of incentive spirometry vs. other therapies. CI=confidence interval; PPC=postoperative pulmonary complications.

Thumbnail

Fig. 5
Meta-analyses of the results for the secondary outcomes of incentive spirometry vs. other therapies. CI=confidence interval; FEV1=forced expiratory volume in one second; FVC=forced vital capacity; PaO2=partial pressure of oxygen; PEF=peak of expiratory flow; SD=standard deviation; VC=vital capacity.

Thumbnail

Fig. 6
Meta-analyses of the results for the primary outcomes of incentive spirometry vs. noninvasive ventilation (NIV). CI=confidence interval; PPC=postoperative pulmonary complications.

Thumbnail

Fig. 7
Meta-analyses of the results for the secondary outcomes of incentive spirometry vs. noninvasive ventilation (NIV). CI=confidence interval; FEV₁=forced expiratory volume in one second; FVC=forced vital capacity; PaO₂=partial pressure of oxygen; SD=standard deviation; SO₂=oxygen saturation; VC=vital capacity.

Thumbnail

Abbreviations, Acronyms & Symbols CABG = Coronary artery bypass grafting MD = Mean differences CENTRAL = Cochrane Central Register of Controlled Trials MIP = Maximal inspiratory pressure CG = Control group NIV = Noninvasive ventilation CI = Confidence interval NR = Not registered CINAHL® = Cumulative Index of Nursing and Allied Health PaO2 = Partial pressure of oxygen CPAP = Continuous positive airway pressure PEDro = Physiotherapy Evidence Database ECC = Extracorporeal circulation PEF = Peak of expiratory flow FEF = Forced expiratory flow PO = Postoperative FEV1 = Forced expiratory volume in one second PPC = Postoperative pulmonary complications FVC = Forced vital capacity RCT = Randomized controlled trial GRADE = Classification of Recommendations, Assessment, Development and Evaluation RR SciELO = Risk ratios = Scientific Electronic Library Online ICU = Intensive care unit SD = Standard deviation IPPB = Intermittent positive pressure breathing SMD = Standardized mean differences IS = Incentive spirometry SO2 = Oxygen saturation ISG = Incentive spirometry group VC = Vital capacity LILACS = Latin American and Caribbean Health Sciences Literature VR = Valve replacement LOS = Length of stay

Thumbnail

Table 1
Characteristics of the studies included in the systematic review.

Thumbnail

Table 2
Characteristics of the surgery and intervention.

Thumbnail

Table 3
Summary of findings for clinical outcomes.

Thumbnail

Table 4
Summary of findings for clinical outcomes.

Thumbnail

Table 5
Quality assessment of the clinical trials using the Physiotherapy Evidence Database (or PEDro) scale.

Thumbnail

14.08.2020 Medical Literature Analysis and Retrieval System Online (or MEDLINE®) via PubMed® - 175 results #1 ("Cardiac Surgical Procedures"[Mesh]) OR "Heart Surg*" OR "Cardiac Surg*" OR "Cardiovascular Surg*" OR ("Coronary Artery Bypass"[Mesh]) OR (Coronary Artery Bypass Grafting) OR CABG OR (Heart Bypass) OR (Coronary Bypass) OR (Aortocoronary Bypass) OR ("Myocardial Revascularization"[Mesh]) OR (Transmyocardial Revascularization) OR (Heart Myectomy) OR (Heart Myotomy) OR ("Cardiopulmonary Bypass"[Mesh]) OR (Heart-Lung Bypass) OR (Cardiology Robotic Surgery) OR ("Angioplasty"[Mesh]) OR ("Balloon Valvuloplasty"[Mesh]) OR (Valve Repair) OR (Valvular Surgery) OR (Valve Surgery) OR ("Cardiac Valve Annuloplasty"[Mesh]) OR Annuloplasty OR (Cardiac Valve Annulus Repair) OR (Heart Valve Annulus Repair) OR (Cardiac Valve Annular Reduction) OR (Cardiac Valve Annulus Shortening) OR (Cardiac Valve Annulus Reduction) OR (Valve Replacement) OR ("Transcatheter Aortic Valve Replacement"[Mesh]) OR TAVR OR ("Heart Valve Prosthesis Implantation"[Mesh]) OR (Insertion of Pacemaker) OR (Insertion of implantable cardioverter defibrillator) OR (Maze Surgery) OR (Aortic Aneurysm Repair) OR (Aortic Surgery) OR ("Heart Transplantation"[Mesh]) OR "Heart Transplant*" OR (Heart Grafting) OR "Cardiac Transplant*" OR (Insertion of Ventricular Assist Device) OR (VAD Surgery) OR (Insertion of Total Artificial Heart) OR ("Thoracic Surgery"[Mesh]) OR ("Thoracic Surgical Procedures"[Mesh]) OR "Thoracic Surg*" OR (Arrhythmia Surgery) OR (Left Ventricular Remodeling) OR (Surgical Ventricular Restoration) OR (Atrial Fibrillation Ablation) OR (Atrial Fibrillation Surgery) OR (Hypertrophic Cardiomyopathy Surgery) OR (Thoracoscopic Surgical Procedures) OR (Thoracoscopic Surgeries) OR ("Thoracotomy"[Mesh]) OR Thoracotomies OR Thoracostomy OR ("Thoracic Surgery, Video-Assisted"[Mesh]) OR (Video-Assisted Thoracic Surgery) OR VATS #2 ("Breathing Exercises"[Mesh]) OR "Incentive Spiromet*" OR (Flow-Incentive Spirometer) OR Triflo OR Triflow OR Voldyne OR respiron #3 ((((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials as topic[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading]))) #4 #1 AND #2 AND #3 Embase® via Elsevier - 304 results #1 'heart surgery'/exp OR 'heart surg*' OR 'cardiac surg*' OR 'cardiosurgery' OR 'heart operation' OR 'myocardial resection' OR 'surgery, heart' OR 'open heart surgery'/exp OR 'intracardiac surgery' OR 'minimally invasive cardiac surgery'/exp OR 'coronary artery bypass graft'/exp OR 'coronary artery bypass' OR 'aorta coronary artery bypass' OR 'aorta coronary bypass' OR 'aorta coronary vein bypass' OR 'aorta coronary vein shunt' OR 'aortic coronary artery bypass' OR 'aortic coronary bypass' OR 'aorticocoronary anastomosis' OR 'aorto coronary artery bypass' OR 'aorto coronary bypass' OR 'aorto coronary vein bypass' OR 'aortocoronary anastomosis' OR 'aortocoronary artery bypass' OR 'aortocoronary artery bypass' OR 'aortocoronary bypass' OR 'aortocoronary shunt' OR 'aortocoronary vein bypass' OR 'aortocoronary venous bypass' OR 'coronary artery graft' OR 'coronary bypass' OR 'coronary vein bypass' OR 'coronary venous bypass' OR 'heart muscle revascularization'/exp OR 'heart muscle revascularization' OR 'heart muscle revascularisation' OR 'anastomosis, internal mammary artery' OR 'artery implantation, mammary' OR 'implantation, internal mammary artery' OR 'internal mammary arterial anastomosis' OR 'internal mammary arterial implantation' OR 'internal mammary artery anastomosis' OR 'internal mammary artery graft' OR 'internal mammary artery implant' OR 'internal mammary artery implantation' OR 'internal mammary artery reimplantation' OR 'internal mammary-coronary artery anastomosis' OR 'mammary arterial implantation' OR 'mammary artery implantation' OR 'cardiac muscle revascularisation' OR 'cardiac muscle revascularization' OR 'myocardium revascularization' OR 'myocardium revascularisation' OR 'coronary revascularisation' OR 'coronary revascularization' OR 'heart revascularisation' OR 'heart revascularization' OR 'myocardial revascularisation' OR 'myocardial revascularization' OR 'revascularisation, transmyocardial laser' OR 'revascularization, transmyocardial laser' OR 'transmyocardial laser revascularisation' OR 'transmyocardial laser revascularization' OR 'vineberg operation' OR 'cardiopulmonary bypass'/exp OR 'cardiopulmonary bypass' OR 'atriopulmonary shunt' OR 'bypass, cardiopulmonary' OR 'cardiopulmonary shunt' OR 'heart lung bypass' OR 'angioplasty'/exp OR 'angioplasty' OR 'transluminal coronary angioplasty'/exp OR 'coronary artery dilatation, transluminal' OR p.t.c.a. OR ptca OR 'transluminal valvuloplasty'/exp OR 'transluminal valvuloplasty' OR 'balloon valvotomy' OR valvuloplasty OR valvulotomy OR 'valve repair' OR valvotomy OR valvulotomy OR 'annuloplasty'/exp OR annuloplasty OR 'heart valve replacement'/exp OR 'valve replacement' OR 'valvular replacement' OR 'valve implantation' OR 'valve prosthesis implantation' OR 'valvular replacement' OR 'transcatheter aortic valve implantation'/exp OR TAVI OR 'pacemaker implantation'/exp OR 'pacemaker implantation' OR 'artificial heart pacemaker implantation' OR 'heart pacemaker implantation' OR 'maze procedure'/exp OR 'maze procedure' OR 'Cox maze operation' OR 'Cox maze procedure' OR 'Cox maze surgery' OR 'Cox-maze ablation' OR 'Cox-maze technique' OR 'maze ablation' OR 'maze operation' OR 'maze surgery' OR 'maze technique' OR 'surgical Cox-maze procedure' OR 'surgical maze' OR 'aortic aneurysm surgery'/exp OR 'aortic aneurysm surgery' OR 'aortic surgery'/exp OR 'aortic surgery' OR 'aorta surgery' OR 'aortopexy' OR 'surgery, aorta' OR 'heart transplantation'/exp OR 'heart transplant*' OR 'cardiac transplant*' OR 'heart allograft' OR 'heart allotransplantation' OR 'heart heterograft' OR 'transplant, heart' OR 'heart heterotransplantation' OR 'heart homograft' OR 'heart homotransplantation' OR 'heart orthotopic transplantation' OR 'heart tissue transplantation' OR 'heart ventricle transplantation' OR 'heart graft'/exp OR 'heart graft' OR 'cardiac graft' OR 'graft, heart' OR 'Ventricular Assist Device Surg*' OR 'Insertion of Total Artificial Heart' OR 'thorax surgery'/exp OR 'thorax surg*' OR 'cardiothoracic surg*' OR 'chest surg*' OR 'chest wall surg*' OR 'surgery, chest' OR 'surgery, thoracic' OR 'surgery, thorax' OR 'thoracic operation' OR 'thoracic surg*' OR 'left ventricular remodeling'/exp OR 'left ventricular remodeling' OR 'surgical ventricular restoration'/exp OR 'surgical ventricular restoration' OR 'atrial fibrillation ablation'/exp OR 'atrial fibrillation ablation' OR 'thoracoscopic surgery'/exp OR 'thoracoscopic surg*' OR 'thoracotomy'/exp OR thoracotomy OR 'video assisted thoracoscopic surgery'/exp OR 'video assisted thoracoscopic surg*' #2 'breathing exercise'/exp OR 'breathing exercise' OR 'incentive spirometry'/exp OR 'incentive spiromet*' OR 'incentive spirometer'/exp OR 'Respiflo 5000' OR Coach OR Triflo OR Triflow OR Voldyne OR respiron #3 'crossover procedure':de OR 'double-blind procedure':de OR 'randomized controlled trial':de OR 'single-blind procedure':de OR (random* OR factorial* OR crossover* OR cross NEXT/1 over* OR placebo* OR doubl* NEAR/1 blind* OR singl* NEAR/1 blind* OR assign* OR allocat* OR volunteer*):de,ab,ti #4 #1 AND #2 AND #3 Cochrane Central Register of Controlled Trials (or CENTRAL) via Cochrane Library - 136 results #1 MeSH descriptor: [Cardiac Surgical Procedures] explode all trees #2 MeSH descriptor: [Coronary Artery Bypass] explode all trees #3 MeSH descriptor: [Myocardial Revascularization] explode all trees #4 MeSH descriptor: [Cardiopulmonary Bypass] explode all trees #5 MeSH descriptor: [Angioplasty] explode all trees #6 MeSH descriptor: [Balloon Valvuloplasty] explode all trees #7 MeSH descriptor: [Cardiac Valve Annuloplasty] explode all trees #8 MeSH descriptor: [Transcatheter Aortic Valve Replacement] explode all trees #9 MeSH descriptor: [Heart Valve Prosthesis Implantation] explode all trees #10 MeSH descriptor: [Heart Transplantation] explode all trees #11 MeSH descriptor: [Thoracic Surgical Procedures] explode all trees #12 MeSH descriptor: [Thoracotomy] explode all trees #13 MeSH descriptor: [Thoracic Surgery, Video-Assisted] explode all trees #14 MeSH descriptor: [Thoracic Surgery] explode all trees #15 "Heart Surg*" OR "Cardiac Surg*" OR "Cardiovascular Surg*" OR (Coronary Artery Bypass Grafting) OR CABG OR (Heart Bypass) OR (Coronary Bypass) OR (Aortocoronary Bypass) OR (Myocardial Revascularization) OR (Transmyocardial Revascularization) OR (Heart Myectomy) OR (Heart Myotomy) OR (Heart-Lung Bypass) OR (Cardiology Robotic Surgery) OR (Valve Repair) OR (Valvular Surgery) OR (Valve Surgery) OR Annuloplasty OR (Cardiac Valve Annulus Repair) OR (Heart Valve Annulus Repair) OR (Cardiac Valve Annular Reduction) OR (Cardiac Valve Annulus Shortening) OR (Cardiac Valve Annulus Reduction) OR (Valve Replacement) OR TAVR OR (Insertion of Pacemaker) OR (Insertion of implantable cardioverter defibrillator) OR (Maze Surgery) OR (Aortic Aneurysm Repair) OR (Aortic Surgery) OR "Heart Transplant*" OR (Heart Grafting) OR "Cardiac Transplant*" OR (Insertion of Ventricular Assist Device) OR (VAD Surgery) OR (Insertion of Total Artificial Heart) OR "Thoracic Surg*" OR (Arrhythmia Surgery) OR (Left Ventricular Remodeling) OR (Surgical Ventricular Restoration) OR (Atrial Fibrillation Ablation) OR (Atrial Fibrillation Surgery) OR (Hypertrophic Cardiomyopathy Surgery) OR (Thoracoscopic Surgical Procedures) OR (Thoracoscopic Surgeries) OR Thoracotomies OR Thoracostomy OR (Video-Assisted Thoracic Surgery) OR VATS #16 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 #17 MeSH descriptor: [Breathing Exercises] explode all trees #18 Incentive Spirometr* OR (Flow-Incentive Spirometer) OR Coach OR Triflo OR Triflow OR Voldyne OR respiron #19 #17 OR #18 #20 #16 AND #19 Latin American and Caribbean Health Sciences Literature (LILACS) via Virtual Health Library Regional Portal - 46 results #1 MH:"Procedimentos Cirúrgicos Cardíacos" OR (Cardiac Surgical Procedures) OR (Procedimientos Quirúrgicos Cardíacos) OR MH:E04.100.376$ OR MH:E04.928.220$ OR MH:"Ponte de Artéria Coronária" OR (Coronary Artery Bypass) OR (Puente de Arteria Coronaria) OR (Derivação da Artéria Coronária) OR (Ponte Aortocoronária) OR MH:E04.100.376.719.332$ OR MH:E04.100.814.868.750$ OR MH:E04.928.220.520.220$ OR MH:"Ponte Cardiopulmonar" OR (Cardiopulmonary Bypass) OR (Puente Cardiopulmonar) OR (Circuito Cardiopulmonar) OR (Derivação Cardiopulmonar) OR (Ponte Coração-Pulmão) OR MH:E04.292.413$ OR MH:Angioplastia OR Angioplasty OR MH:E02.148.050 OR MH:E04.100.814.529.124$ OR MH:E04.502.382.124$ OR MH:E05.157.016$ OR MH:"Valvuloplastia com Balão" OR Valvuloplasty OR Valvuloplastia OR MH:E02.148.108$ OR MH:E05.157.125$ OR MH:"Anuloplastia da Valva Cardíaca" OR (Cardiac Valve Annuloplasty) OR (Anuloplastia de la Válvula Cardíaca) OR (Anuloplastia Valvar Cardíaca) OR (Anuloplastia da Válvula Cardíaca) OR MH:E04.100.376.062$ OR MH:E04.928.220.109$ OR MH:"Substituição da Valva Aórtica Transcateter" OR (Transcatheter Aortic Valve Replacement) OR (Reemplazo de la Válvula Aórtica Transcatéter) OR MH:E04.100.376.485.500$ OR MH:E04.650.410.500$ OR MH:E04.928.220.410.500$ OR MH:"Implante de Prótese de Valva Cardíaca" OR (Heart Valve Prosthesis Implantation) OR (Implantación de Prótesis de Válvulas Cardíacas) OR (Implantação de Prótese Valvar Cardíaca) OR (Implantação de Prótese de Valva) OR (Implantação de Prótese de Valva Cardíaca) OR (Implante de Prótese Valvar Cardíaca) OR (Implante de Prótese de Valva) OR MH:E04.100.376.485$ OR MH:E04.650.410$ OR MH:E04.928.220.410$ OR MH:"Transplante de Coração" OR (Heart Transplantation) OR (Trasplante de Corazón) OR (Enxerto Cardíaco) OR (Enxerto de Coração) OR (Transplantação Cardíaco) OR (Transplantação de Coração) OR (Transplante Cardíaco) OR MH:E04.100.376.475$ OR MH:E04.928.220.390$ OR MH:E04.936.450.475$ OR MH:"Procedimentos Cirúrgicos Torácicos" OR (Thoracic Surgical Procedures) OR (Procedimientos Quirúrgicos Torácicos) MH:E04.928$ OR MH:Toracotomia OR Thoracotomy OR Toracotomía OR MH:E04.928.760$ OR MH:"Cirurgia Torácica Vídeoassistida" OR MH:"Thoracic Surgery, Video-Assisted" OR (Cirugía Torácica Asistida por Video) OR CTVA OR VATS OR MH:E01.370.388.250.840.830$ OR MH:E01.370.388.250.950.830$ OR MH:E04.502.250.840.830$ OR MH:E04.502.250.950.830$ OR MH:E04.928.752.830$ #2 MH:"Exercícios Respiratórios" OR (Breathing Exercises) OR (Ejercicios Respiratorios) OR (Exercício Respiratório) OR (Exercícios para os Músculos Respiratórios) OR MH:E02.190.525.186$ OR MH:E02.779.474.124$ OR (Espirometria de incentivo) OR Voldyne OR Triflo OR Triflow Filter: LILACS PEDro - 1st search - 47 results / 2nd search - 81 results #1 Heart Surg* / Subdiscipline: Cardiothoracics / Therapy: Respiratory Therapy / Method: Clinical trial #2 Cardiac Surg* / Subdiscipline: Cardiothoracics / Therapy: Respiratory Therapy / Method: Clinical trial Cumulative Index of Nursing and Allied Health (or CINAHL®) via EBSCO - 80 results S1 (MM "Surgery, Cardiovascular+") OR (MM "Thoracic Surgery, Video-Assisted") OR (MM "Thoracic Surgery+") OR (MM "Coronary Artery Bypass+") OR (MM "Myocardial Revascularization+") OR (MM "Angioplasty, Transluminal, Percutaneous Coronary") OR (MM "Cardiopulmonary Bypass") OR (MM "Angioplasty+") OR (MM "Angioplasty, Balloon, Laser-Assisted") OR (MM "Angioplasty, Balloon+") OR (MM "Angioplasty, Laser+") OR (MM "Percutaneous Coronary Intervention") OR (MM "Balloon Dilatation+") OR (MM "Cardiac Valve Annuloplasty+") OR (MM "Mitral Valve Annuloplasty") OR (MM "Transcatheter Aortic Valve Implantation") OR (MM "Heart Valve Prosthesis") OR (MM "Heart Transplantation+") OR (MM "Heart-Lung Transplantation") OR (MM "Thoracotomy") OR (MM "Thoracostomy+") S2 "Heart Surg*" OR "Cardiac Surg*" OR "Cardiovascular Surg*" OR (Coronary Artery Bypass Grafting) OR CABG OR (Heart Bypass) OR (Coronary Bypass) OR (Aortocoronary Bypass) OR (Myocardial Revascularization) OR (Transmyocardial Revascularization) OR (Heart Myectomy) OR (Heart Myotomy) OR (Heart-Lung Bypass) OR (Cardiology Robotic Surgery) OR (Valve Repair) OR (Valvular Surgery) OR (Valve Surgery) OR Annuloplasty OR (Cardiac Valve Annulus Repair) OR (Heart Valve Annulus Repair) OR (Cardiac Valve Annular Reduction) OR (Cardiac Valve Annulus Shortening) OR (Cardiac Valve Annulus Reduction) OR (Valve Replacement) OR TAVR OR (Insertion of Pacemaker) OR (Insertion of implantable cardioverter defibrillator) OR (Maze Surgery) OR (Aortic Aneurysm Repair) OR (Aortic Surgery) OR "Heart Transplant*" OR (Heart Grafting) OR "Cardiac Transplant*" OR (Insertion of Ventricular Assist Device) OR (VAD Surgery) OR (Insertion of Total Artificial Heart) OR "Thoracic Surg*" OR (Arrhythmia Surgery) OR (Left Ventricular Remodeling) OR (Surgical Ventricular Restoration) OR (Atrial Fibrillation Ablation) OR (Atrial Fibrillation Surgery) OR (Hypertrophic Cardiomyopathy Surgery) OR (Thoracoscopic Surgical Procedures) OR (Thoracoscopic Surgeries) OR Thoracotomies OR Thoracostomy OR (Video-Assisted Thoracic Surgery) OR VATS S3 S1 OR S2 S4 (MM "Breathing Exercises+") S5 "Incentive Spiromet*" OR (Flow-Incentive Spirometer) OR Triflo OR Triflow OR Voldyne OR respiron S6 S4 OR S5 S7 S3 AND S6 S8 TX allocat* random* OR (MH "Quantitative Studies") OR (MH "Placebos") OR TX placebo* OR TX random* allocat* OR (MH "Random Assignment") OR TX randomi* control* trial* OR TX ((singl* n1 blind*) OR (singl* n1 mask*) ) OR TX ( (doubl* n1 blind*) OR (doubl* n1 mask*) ) OR TX ( (tripl* n1 blind*) OR (tripl* n1 mask*) ) OR TX ( (trebl* n1 blind*) OR (trebl* n1 mask*) ) OR TX clinic* n1 trial* OR PT Clinical trial OR (MH "Clinical Trials+") S9 S7 AND S9 Scopus® via Elsevier - 810 results #1 TITLE-ABS-KEY("Cardiac Surgi*" OR "Coronary Artery Bypass" "Myocardial Revascularization" OR "Cardiopulmonary Bypass" OR Angioplasty "Balloon Valvuloplasty" OR "Cardiac Valve Annuloplasty" OR "Transcatheter Aortic Valve Replacement" "Heart Valve Prosthesis Implantation" OR "Heart Transplant*" OR "Thoracic Surg*") #2 "Heart Surg*" OR "Cardiac Surg*" OR "Cardiovascular Surg*" OR "Coronary Artery Bypass Graf*" OR CABG OR "Heart Bypass" OR "Coronary Bypass" OR "Aortocoronary Bypass" OR "Myocardial Revascularization" OR "Transmyocardial Revascularization" OR "Heart Myectomy" OR "Heart Myotomy" OR "Heart-Lung Bypass" OR "Cardiology Robotic Surg*" OR "Valve Repair" OR "Valvular Surg*" OR "Valve Surg*" OR Annuloplasty OR "Cardiac Valve Annulus Repair" OR "Heart Valve Annulus Repair" OR "Cardiac Valve Annular Reduction" OR "Cardiac Valve Annulus Shortening" OR "Cardiac Valve Annulus Reduction" OR "Valve Replacement" OR TAVR OR "Insertion of Pacemaker" OR "Insertion of implantable cardioverter defibrillator" OR "Maze Surg*" OR "Aortic Aneurysm Repair" OR "Aortic Surg*" OR "Heart Transplant*" OR "Heart Graft*" OR "Cardiac Transplant*" OR "Insertion of Ventricular Assist Device" OR "VAD Surg*" OR "Insertion of Total Artificial Heart" OR "Thoracic Surg*" OR "Arrhythmia Surg*" OR "Left Ventricular Remodeling" OR "Surgical Ventricular Restoration" OR "Atrial Fibrillation Ablation" OR "Atrial Fibrillation Surg*" OR "Hypertrophic Cardiomyopathy Surg*" OR "Thoracoscopic Surg*" OR Thoracotom* OR Thoracostomy OR "Video-Assisted Thoracic Surg*" OR VATS #3 #1 OR #2 #4 TITLE-ABS-KEY("Breathing Exercis*") #5 "Incentive Spirometr*" OR (Flow-Incentive Spirometer) OR Coach OR Triflo OR Triflow OR Voldyne OR respiron #6 #4 OR #5 #7 #3 AND #6 #8 TITLE-ABS-KEY((clinic* w/1 trial*) OR (randomi* w/1 control*) OR (randomi* w/2 trial*) OR (random* w/1 assign*) OR (random* w/1 allocat*) OR (control* w/1 clinic*) OR (control* w/1 trial) OR placebo* OR (Quantitat* w/1 Stud*) OR (control* w/1 stud*) OR (randomi* w/1 stud*) OR (singl* w/1 blind*) OR (singl* w/1 mask*) OR (doubl* w/1 blind*) OR (doubl* w/1 mask*) OR (tripl* w/1 blind*) OR (tripl* w/1 mask*) OR (trebl* w/1 blind*) OR (trebl* w/1 mask*)) AND NOT (SRCTYPE(b) OR SRCTYPE(k) OR SRCTYPE(p) OR SRCTYPE(r) OR SRCTYPE(d) OR DOCTYPE(ab) OR DOCTYPE(bk) OR DOCTYPE(ch) OR DOCTYPE(bz) OR DOCTYPE(cr) OR DOCTYPE(ed) OR DOCTYPE(er) OR DOCTYPE(le) OR DOCTYPE(no) OR DOCTYPE(pr) OR DOCTYPE(rp) OR DOCTYPE(re) OR DOCTYPE(sh)) #9 #7 AND #8 SciELO - 1st search - 3 results / 2nd search - 4 results #1 (Heart Surg*) AND (Incentive Spiromet*) #2 (Cardiac Surg*) AND (Incentive Spiromet*) OpenGrey Database - 0 results Incentive Spiromet* ClinicalTrials.gov - 6 results Condition: (Cardiac Surg*) OR (Heart Surg*) OR (Thoracic Surg*) Other terms: (Breathing Exercis*) OR (Incentive Spiromet*) OR (Flow-Incentive Spirometer) OR Triflo OR Triflow OR Voldyne OR respiron clinicaltrialsregister.eu - 0 results #1 Incentive Spiromet* Rebec - 0 results #1 Cardiac Surg* #2 Heart Surg* World Health Organization International Clinical Trials Registry Platform - No access at the time of search. #1 (Heart Surg*) AND (Incentive Spiromet*) #2 (Cardiac Surg*) AND (Incentive Spiromet*)

Thumbnail

Question 1: Incentive spirometry vs. respiratory care in patients undergoing cardiac surgery. Question 2: Incentive spirometry vs. other therapies in patients undergoing cardiac surgery. Question 3: Incentive spirometry vs. noninvasive ventilation in patients undergoing cardiac surgery. Certainty assessment No. of patients Effect Certainty Importance No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Incentive spirometry Control Relative (95% CI) Absolute (95% CI) IS vs. Respiratory care - Postoperative pulmonary complications (assessed with: number of events [pneumonia and atelectasis] recorded) 4 Randomized trials *Very seriousa,b,c,d Not serious Not serious Not serious None 45/189 (24.2%) 65/203 (32.0%) RR 0.91 (0.72 to 1.14) 29 fewer per 1,000 (from 90 fewer to 45 more) ⨁⨁◯◯ Low Critical IS vs. Respiratory care - LOS (assessed with: number of days spent in hospital) 3 Randomized trials *Very seriousa,b,c,d,j Not serious Not serious *Seriousi None 145 146 - MD 1.38 lower (2.96 lower to 0.21 higher) ⨁◯◯◯ Very low Important IS vs. Respiratory care - Length of ICU stay (assessed with: number of days spend in ICU) 2 Randomized trials *Very seriousb,c,e,f,g,h Not serious Not serious *Seriousi None 26 26 - MD 0.78 lower (1.61 lower to 0.06 higher) ⨁◯◯◯ Very low Critical IS vs. Respiratory care - Peak of expiratory flow (assessed with: spirometry [L/min]) 2 Randomized trials *Very seriousb,c,e,f Not serious Not serious *Seriousi None 49 65 - MD 0.59 lower (1.97 lower to 0.78 higher) ⨁◯◯◯ Very low Important IS vs. Respiratory care - Forced expiratory volume in one second (assessed with: spirometry [% and liters]) 5 Randomized trials *Very seriousb,c,e,f Not serious Not serious Not serious None 203 200 - SMD 0.16 SD lower (0.48 lower to 0.16 higher) ⨁⨁◯◯ Low Important IS vs. Respiratory care - Forced vital capacity (assessed with: spirometry [% and liters]) 5 Randomized trials *Very seriousb,c,e,f *Seriousk Not serious Not serious None 203 200 - SMD 0.14 SD higher (0.4 lower to 0.67 higher) ⨁◯◯◯ Very low Important IS vs. Respiratory care - Vital capacity (assessed with: spirometry [% and liters]) 3 Randomized trials *Very seriousb,c,e,f,j,l *Seriousk Not serious Not serious None 57 73 - SMD 0.38 SD higher (0.59 lower to 1.34 higher) ⨁◯◯◯ Very low Important IS vs. Respiratory care - Arterial oxygen partial pressure (mmHg) 6 Randomized trials *Very seriousb,c,e,f,j,l *Seriousk Not serious Not serious None 125 157 - MD 4.48 lower (8.32 lower to 0.63 lower) ⨁◯◯◯ Very low Critical IS vs. Respiratory care - Oxygen saturation (%) 3 Randomized trials *Very seriousb,c,e,f,j,l *Seriousk Not serious Not serious None 71 71 - MD 2.54 higher (1.74 lower to 6.82 higher) ⨁◯◯◯ Very low Critical IS vs. Other therapies - Postoperative pulmonary complications (assessed with: number of events [pneumonia and atelectasis] recorded) 3 Randomized trials *Very seriousb,c,e,f,l *Seriousk Not serious Not serious None 38/54 (70.4%) 63/95 (66.3%) RR 1.04 (0.73 to 1.49) 27 more per 1,000 (from 179 fewer to 325 more) ⨁◯◯◯Very low Critical IS vs. Other therapies - Forced expiratory volume in one second (assessed with: spirometry [liters]) 2 Randomized trials *Very seriousb,c,e,f Not serious Not serious *Seriousi None 25 50 - MD 0.08 higher (0.08 lower to 0.25 higher) ⨁◯◯◯ Very low Important IS vs. Other therapies - Forced vital capacity (assessed with: spirometry [% and liters]) 3 Randomized trials *Very seriousb,c,e,f,j,l Not serious Not serious *Seriousi None 37 73 - SMD 0.15 SD higher (0.25 lower to 0.55 higher) ⨁◯◯◯ Very low Important IS vs. Other therapies - Arterial oxygen partial pressure (mmHg) 3 Randomized trials *Very seriousb,c,e,f,j,l *Seriousk Not serious Not serious None 44 87 - MD 3.63 lower (9.18 lower to 1.93 higher) ⨁◯◯◯ Very low Critical IS vs. NIV - Postoperative pulmonary complications (assessed with: number of events [pneumonia and atelectasis] recorded) 4 Randomized trials *Very seriousb,c,e,f,l *Seriousk Not serious Not serious None 95/113 (84.1%) 106/138 (76.8%) "RR 1.14 (0.84 to 1.55)" 108 more per 1,000 (from 123 fewer to 422 more) ⨁◯◯◯ Very low Critical IS vs. NIV - Mortality (assessed with: number of events recorded) 2 Randomized trials *Very seriousb,c,e,f,h Not serious Not serious *Seriousi None 0/65 (0.0%) 4/114 (3.5%) RR 0.49 (0.08 to 2.93) 18 fewer per 1,000 (from 32 fewer to 68 more) ⨁◯◯◯ Very low Critical IS vs. NIV - Adverse events (assessed with: number of events recorded) 3 Randomized trials *Very seriousb,c,e,f,l Not serious Not serious *Seriousi None 13/61 (21.3%) 14/81 (17.3%) RR 1.10 (0.62 to 1.95) 17 more per 1,000 (from 66 fewer to 164 more) ⨁◯◯◯ Very low Critical IS vs. NIV - Arterial oxygen partial pressure (mmHg) 4 Randomized trials *Very seriousb,c,e,f,l *Seriousk Not serious Not serious None 96 120 - MD 2.95 higher (4.69 lower to 10.58 higher) ⨁◯◯◯ Very low Critical IS vs. NIV - Oxygen saturation (%) 2 Randomized trials *Very seriousb,c,e,f,h *Seriousk Not serious Not serious None 56 92 - MD 0.99 lower (2.12 lower to 0.14 higher) ⨁◯◯◯ Very low Critical CI=confidence interval; ICU=intensive care unit; IS=incentive spirometry; LOS=length of stay; MD=mean difference; NIV=noninvasive ventilation; RR=risk ratio; SD=standard deviation; SMD=standardized mean difference *For very serious limitations, we downgraded two levels, and for serious limitations, we downgraded one level a. Allocation was not concealed in most studies b. There was no blinding of all subjects in the studies c. There was no blinding of all therapists who administered the therapy d. Data for at least one key outcome was not analyzed by “intention to treat” in most studies e. Allocation was not concealed f. Data for at least one key outcome was not analyzed by “intention to treat” g. Measures of at least one key outcome were not obtained from > 85% of the subjects initially allocated to groups h. There was no blinding of all assessors who measured at least one key outcome i. Imprecision with few studies and few participants j. Measures of at least one key outcome were not obtained from > 85% of the subjects initially allocated to groups in most studies l. There was no blinding of all assessors who measured at least one key outcome in most studies

Abbreviations, Acronyms & Symbols
CABG	= Coronary artery bypass grafting	MD	= Mean differences
CENTRAL	= Cochrane Central Register of Controlled Trials	MIP	= Maximal inspiratory pressure
CG	= Control group	NIV	= Noninvasive ventilation
CI	= Confidence interval	NR	= Not registered
CINAHL®	= Cumulative Index of Nursing and Allied Health	PaO₂	= Partial pressure of oxygen
CPAP	= Continuous positive airway pressure	PEDro	= Physiotherapy Evidence Database
ECC	= Extracorporeal circulation	PEF	= Peak of expiratory flow
FEF	= Forced expiratory flow	PO	= Postoperative
FEV₁	= Forced expiratory volume in one second	PPC	= Postoperative pulmonary complications
FVC	= Forced vital capacity	RCT	= Randomized controlled trial
GRADE	= Classification of Recommendations, Assessment, Development and Evaluation	RR SciELO	= Risk ratios = Scientific Electronic Library Online
ICU	= Intensive care unit	SD	= Standard deviation
IPPB	= Intermittent positive pressure breathing	SMD	= Standardized mean differences
IS	= Incentive spirometry	SO₂	= Oxygen saturation
ISG	= Incentive spirometry group	VC	= Vital capacity
LILACS	= Latin American and Caribbean Health Sciences Literature	VR	= Valve replacement
LOS	= Length of stay

Study	Total sample size	Total average age (year)	Study follow-up time
Iverson et al., 1978[²⁷27 Iverson LI, Ecker RR, Fox HE, May IA. A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Ann Thorac Surg. 1978;25(3):197-200. doi:10.1016/s0003-4975(10)63521-7. https://doi.org/10.1016/s0003-4975(10)63... ]	145	-	-
Gale and Sanders, 1980[²⁸28 Gale GD, Sanders DE. Incentive spirometry: its value after cardiac surgery. Can Anaesth Soc J. 1980;27(5):475-80. doi:10.1007/BF03007047. https://doi.org/10.1007/BF03007047.... ]	109	-	Until 3^rd PO day, or longer if abnormal signs were present in the chest or on the chest X-ray
Dull and Dull, 1983[²⁹29 Dull JL, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Phys Ther. 1983;63(5):655-9. doi:10.1093/ptj/63.5.655. https://doi.org/10.1093/ptj/63.5.655.... ]	49	57.9	Until 3^rd PO day
Stock et al., 1984[²⁴24 Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, et al. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Crit Care Med. 1984;12(11):969-72. doi:10.1097/00003246-198411000-00010. https://doi.org/10.1097/00003246-1984110... ]	38	57.3	Until 3^rd PO day
Jenkins et al., 1989[³⁰30 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax. 1989;44(8):634-9. doi:10.1136/thx.44.8.634. https://doi.org/10.1136/thx.44.8.634.... ]	110	55	Until 5^th PO day
Jenkins et al., 1990[³¹31 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. A comparison of breathing exercises, incentive spirometry and mobilisation after coronary artery surgery. Physiother Theory Pract. 1990;6:117-26. doi:10.3109/09593989009037789. https://doi.org/10.3109/0959398900903778... ]	110	38.3	Until 5^th PO day
Oikkonen et al., 1991[³²32 Oikkonen M, Karjalainen K, Kähärä V, Kuosa R, Schavikin L. Comparison of incentive spirometry and intermittent positive pressure breathing after coronary artery bypass graft. Chest. 1991;99(1):60-5. doi:10.1378/chest.99.1.60. https://doi.org/10.1378/chest.99.1.60.... ]	52	55	Until 7^th PO day
Crowe and Bradley, 1997[³³33 Crowe JM, Bradley CA. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther. 1997;77(3):260-8. doi:10.1093/ptj/77.3.260. https://doi.org/10.1093/ptj/77.3.260.... ]	185	64.4	Until hospital discharge
Savci et al., 2006[³⁴34 Savcı S, Sakınç S, İnce DI, Arikan H, Can Z, Buran Y, et al. Active cycle of breathing techniques and incentive spirometer in coronary artery bypass graft surgery. Fizyoter Rehabil. 2006;17(2):61-9.]	60	56.2	Until 5^th PO day
Romanini et al., 2007[³⁵35 Romanini W, Muller AP, Carvalho KA, Olandoski M, Faria-Neto JR, Mendes FL, et al. The effects of intermittent positive pressure and incentive spirometry in the postoperative of myocardial revascularization. Arq Bras Cardiol. 2007;89(2):94-9, 105-10. doi:10.1590/s0066-782x2007001400006. https://doi.org/10.1590/s0066-782x200700... ]	40	56.75	Until 3^rd PO day
Renault et al., 2009[³⁶36 Renault JA, Costa-Val R, Rosseti MB, Houri Neto M. Comparison between deep breathing exercises and incentive spirometry after CABG surgery. Rev Bras Cir Cardiovasc. 2009;24(2):165-72. doi:10.1590/s0102-76382009000200012. https://doi.org/10.1590/s0102-7638200900... ]	36	56.8	Until 7^th PO day
Dias et al., 2011[³⁷37 Dias CM, Vieira Rde O, Oliveira JF, Lopes AJ, Menezes SL, Guimarães FS. Three physiotherapy protocols: effects on pulmonary volumes after cardiac surgery. J Bras Pneumol. 2011;37(1):54-60. doi:10.1590/s1806-37132011000100009. https://doi.org/10.1590/s1806-3713201100... ]	35	62.3	Until 5^th PO day
El-Kader, 2011[³⁸38 El-Kader SMA. Blood gases response to different breathing modalities in phase I of cardiac rehabilitation program after coronary artery bypass graft. Eur J Gen Med. 2011;8(2):85-91. doi.org/10.29333/ejgm/82706. https://doi.org/doi.org/10.29333/ejgm/82... ]	36	48.6	Until 10^th PO day
Al-Mutairi et al., 2012a[³⁹39 Almutairi F, Fallows S, Mason-Whitehead E. Continuous positive airway pressure (cpap) had better outcomes when compared with incentive spirometry (IS) to re-open collapse alveoli after cardiac surgery: randomized study. Am J Respir Crit Care Med. 2012;185:A4869. doi:10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A4869. https://doi.org/10.1164/ajrccm-conferenc... ]	72	57	Until 2^nd PO day
Al-Mutairi et al., 2012b[⁴⁰40 Al-Mutairi FH, Fallows SJ, Abukhudair WA, Islam BB, Morris MM. Difference between continuous positive airway pressure via mask therapy and incentive spirometry to treat or prevent post-surgical atelectasis. Saudi Med J. 2012;33(11):1190-5.]	108	62	Until 2^nd PO day
Mueenudheen et al., 2012[⁴¹41 Mueenudheen TP, Moiz JA, Gupta VP. A comparative study on the effects of incentive spirometry and deep breathing exercise on pulmonary functions after uncomplicated coronary artery bypass grafting surgery. Indian J Physiother Occup Ther. 2012;6(2):63-7.]	32	53.87	Until 3^rd PO day
Rizwan et al., 2012[⁴²42 Rizwan A, Jalwan J, Mukherjee S. To compare the immediate effect of deep breathing exercise and incentive spirometry on ABG after mitral valve replacement surgery. Indian J Physiother Occup Ther. 2012;6(4):12-7.]	32	38.34	Until 2^nd PO day
Zangerolamo et al., 2013[⁴³43 Zangerolamo TB, Barrientos TG, Baltieri L, Moreno M, Pazzianotto-Forti EM. Effects of flow-oriented incentive spirometry after myocardial revascularization. Rev Bras Cardiol. 2013;26(3):180-5.]	16	64.65	Until discharge from the intensive care unit
Yazdannik et al., 2016[⁴⁴44 Yazdannik A, Bollbanabad HM, Mirmohammadsadeghi M, Khalifezade A. The effect of incentive spirometry on arterial blood gases after coronary artery bypass surgery (CABG). Iran J Nurs Midwifery Res. 2016;21(1):89-92. doi:10.4103/1735-9066.174761. https://doi.org/10.4103/1735-9066.174761... ]	50	57.25	Until 3^rd PO day
Manapunsopee et al., 2019[⁴⁵45 Manapunsopee S, Thanakiatpinyo T, Wongkornrat W, Chuaychoo B, Thirapatarapong W. Effectiveness of incentive spirometry on inspiratory muscle strength after coronary artery bypass graft surgery. Heart Lung Circ. 2020;29(8):1180-6. doi:10.1016/j.hlc.2019.09.009. https://doi.org/10.1016/j.hlc.2019.09.00... ]	90	65	Until 4^th PO day
Alam et al., 2020[⁴⁶46 Alam M, Hussain S, Shehzad MI, Mushtaq A, Rauf A, Ishaq S. Comparing the effect of incentive spirometry with acapella on blood gases in physiotherapy after coronary artery bypass graft. Cureus. 2020;12(2):e6851. doi:10.7759/cureus.6851. https://doi.org/10.7759/cureus.6851.... ]	270	46.9	Until 3^rd PO day
Amin et al., 2021[⁴⁷47 Amin R, Alaparthi GK, Samuel SR, Bairapareddy KC, Raghavan H, Vaishali K. Effects of three pulmonary ventilation regimes in patients undergoing coronary artery bypass graft surgery: a randomized clinical trial. Sci Rep. 2021;11(1):6730. doi:10.1038/s41598-021-86281-4. https://doi.org/10.1038/s41598-021-86281... ]	72	62.56	Until 7^th PO day
Barkhordari-Sharifabad et al., 2021[⁴⁸48 Zerang F, Amouzeshi A, Barkhordari-Sharifabad M. Comparison of the effect of incentive spirometry and deep breathing exercises on hemodynamic parameters of patients undergoing coronary artery bypass graft surgery: a clinical trial. J Vasc Nurs. 2022;40(3):134-9. doi:10.1016/j.jvn.2022.08.002. https://doi.org/10.1016/j.jvn.2022.08.00... ]	40	64.1	Until 4^th PO day

Study	Type of surgery	ECC time (minutes)		Intervention with IS		Intervention with standard care
		IS	Standard care	Technique	Frequency of use	Standard care 1		Standard care 2
		IS	Standard care	Technique	Frequency of use	Technique	Frequency of use	Technique	Frequency of use
Iverson et al., 1978[²⁷27 Iverson LI, Ecker RR, Fox HE, May IA. A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Ann Thorac Surg. 1978;25(3):197-200. doi:10.1016/s0003-4975(10)63521-7. https://doi.org/10.1016/s0003-4975(10)63... ]	CABG	-	-	Volume-oriented IS	Three to five times every 3 hours	IPPB	15-min. treatment every 3 hours with 15 to 20 cmH₂0	Blow bottles	Three to five times every 3 hours
Gale and Sanders, 1980[²⁸28 Gale GD, Sanders DE. Incentive spirometry: its value after cardiac surgery. Can Anaesth Soc J. 1980;27(5):475-80. doi:10.1007/BF03007047. https://doi.org/10.1007/BF03007047.... ]	CABG	-	-	Volume-oriented IS	10 deep breaths in a treatment time of 20 min.	IPPB	20 min. with inspiratory pressure of 20 cmH₂O	-	-
Dull and Dull, 1983[²⁹29 Dull JL, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Phys Ther. 1983;63(5):655-9. doi:10.1093/ptj/63.5.655. https://doi.org/10.1093/ptj/63.5.655.... ]	CABG + VR	-		Volume-oriented IS	10 repetitions of maximal inhalation, four times a day	Early mobilization	Early mobilization twice a day	Early mobilization + respiratory care	10 repetitions of maximal inhalation four times a day
Stock et al., 1984[²⁴24 Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, et al. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Crit Care Med. 1984;12(11):969-72. doi:10.1097/00003246-198411000-00010. https://doi.org/10.1097/00003246-1984110... ]	CABG + VR + CABG and VR or aneurysmectomy	-		Volume-oriented IS	15 min. - every 2 hours during waking hours, from the second to the 72^nd hour after extubation	Coughing + deep breathing	15 min. - every 2 hours during waking hours, from the second to the 72^nd hour after extubation	CPAP	Pressure of 7.5 cmH₂O - two or three maximal inspirations every 3 to 5 min.
Jenkins et al., 1989[³⁰30 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax. 1989;44(8):634-9. doi:10.1136/thx.44.8.634. https://doi.org/10.1136/thx.44.8.634.... ]	CABG	-		Flow‑oriented IS	3 to 5 consecutive breaths, at least twice on days 1 and 2 and at least once daily on days 3 to 5	Respiratory care	3 to 5 consecutive deep breaths, at least twice on days 1 and 2 and at least once daily on days 3-5	Airway clearance exercises + physical therapy	3 to 5 consecutive deep breaths, at least twice on days 1 and 2 and at least once daily on days 3-5
Jenkins et al., 1990[³¹31 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. A comparison of breathing exercises, incentive spirometry and mobilisation after coronary artery surgery. Physiother Theory Pract. 1990;6:117-26. doi:10.3109/09593989009037789. https://doi.org/10.3109/0959398900903778... ]	CABG	-		Flow‑oriented IS	Inspiration leaving the balls floating in the first and second chambers - 3 to 5 breaths	Respiratory care	Deep inspiration. Between 3 and 5 consecutive deep breaths	Verbal encouragement	Treatment consisted solely of encouraging (verbally) patients to huff and cough and early mobilization
Oikkonen et al., 1991[³²32 Oikkonen M, Karjalainen K, Kähärä V, Kuosa R, Schavikin L. Comparison of incentive spirometry and intermittent positive pressure breathing after coronary artery bypass graft. Chest. 1991;99(1):60-5. doi:10.1378/chest.99.1.60. https://doi.org/10.1378/chest.99.1.60.... ]	CABG	96 ± 6	108 ± 6	Volume-oriented IS	Inhalation, exceeding 3 seconds and repeated at least 5 times per training	IPPB	Pressure of 10 to 15 cmH₂O - 5 to 10 min. in each session	-	-
Crowe and Bradley, 1997[³³33 Crowe JM, Bradley CA. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther. 1997;77(3):260-8. doi:10.1093/ptj/77.3.260. https://doi.org/10.1093/ptj/77.3.260.... ]	CABG	-	-	Volume-oriented IS	Provided once or twice per day, encouraged by other members of the health care team	Respiratory care	Lung expansion maneuvers and secretion-removal maneuvers. Provided once or twice per day	-	-
Savci et al., 2006[³⁴34 Savcı S, Sakınç S, İnce DI, Arikan H, Can Z, Buran Y, et al. Active cycle of breathing techniques and incentive spirometer in coronary artery bypass graft surgery. Fizyoter Rehabil. 2006;17(2):61-9.]	CABG	-	-	Volume-oriented IS	Twice a day. From the 3^rd day, once a day for 15 min.	Respiratory care	1-2 breathing control breaths	-	-
Romanini et al., 2007[³⁵35 Romanini W, Muller AP, Carvalho KA, Olandoski M, Faria-Neto JR, Mendes FL, et al. The effects of intermittent positive pressure and incentive spirometry in the postoperative of myocardial revascularization. Arq Bras Cardiol. 2007;89(2):94-9, 105-10. doi:10.1590/s0066-782x2007001400006. https://doi.org/10.1590/s0066-782x200700... ]	CABG	57.50 ± 11.53	54 ± 9.26	Volume-oriented IS	10 min., an interval of 5 min. and 10 min. again.	IPPB	10 min., an interval of 5 min. and 10 min. again	-	-
Renault et al., 2009[³⁶36 Renault JA, Costa-Val R, Rosseti MB, Houri Neto M. Comparison between deep breathing exercises and incentive spirometry after CABG surgery. Rev Bras Cir Cardiovasc. 2009;24(2):165-72. doi:10.1590/s0102-76382009000200012. https://doi.org/10.1590/s0102-7638200900... ]	CABG	84.77 ± 32.29	80.94 ± 25.34	Flow‑oriented IS	2 times a day (ICU), and once a day (inpatient unit)	Respiratory care	3 sets of 10 breathing exercises + assisted cough and huffing + early mobilization	-	-
Dias et al., 2011[³⁷37 Dias CM, Vieira Rde O, Oliveira JF, Lopes AJ, Menezes SL, Guimarães FS. Three physiotherapy protocols: effects on pulmonary volumes after cardiac surgery. J Bras Pneumol. 2011;37(1):54-60. doi:10.1590/s1806-37132011000100009. https://doi.org/10.1590/s1806-3713201100... ]	CABG and VR	-	-	Volume-oriented IS	Twice a day for 5 days	Bronchial hygiene + mobilization	Twice a day for 5 days	Bronchial hygiene + mobilization + inspiratory exercise	Twice a day for 5 days
El-Kader, 2011[³⁸38 El-Kader SMA. Blood gases response to different breathing modalities in phase I of cardiac rehabilitation program after coronary artery bypass graft. Eur J Gen Med. 2011;8(2):85-91. doi.org/10.29333/ejgm/82706. https://doi.org/doi.org/10.29333/ejgm/82... ]	CABG	-	-	Volume-oriented IS	Application of 5 min., five times a day	CPAP	Application of 15 min. and pressure = l0 cmH₂O every day	IPPB	Application of IPPB 15 min./day
Al-Mutairi et al., 2012a[³⁹39 Almutairi F, Fallows S, Mason-Whitehead E. Continuous positive airway pressure (cpap) had better outcomes when compared with incentive spirometry (IS) to re-open collapse alveoli after cardiac surgery: randomized study. Am J Respir Crit Care Med. 2012;185:A4869. doi:10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A4869. https://doi.org/10.1164/ajrccm-conferenc... ]	Any heart surgery	-	-	IS	Used IS 15 times per hour for 3 days	CPAP	4-6 cmH₂O	-	-
Al-Mutairi et al., 2012b[⁴⁰40 Al-Mutairi FH, Fallows SJ, Abukhudair WA, Islam BB, Morris MM. Difference between continuous positive airway pressure via mask therapy and incentive spirometry to treat or prevent post-surgical atelectasis. Saudi Med J. 2012;33(11):1190-5.]	Any heart surgery	-	-	Volume-oriented IS	15 times per hour for 3 days	CPAP (2 hours)	4-6 cmH₂O for half hour every 2 hours for 3 days	CPAP (4 hours)	4-6 cmH₂O for half hour every 4 hours for 3 days
Mueenudheen et al., 2012[⁴¹41 Mueenudheen TP, Moiz JA, Gupta VP. A comparative study on the effects of incentive spirometry and deep breathing exercise on pulmonary functions after uncomplicated coronary artery bypass grafting surgery. Indian J Physiother Occup Ther. 2012;6(2):63-7.]	CABG	-	-	Flow‑oriented IS	3 sets of 10 breaths with a pause of 1 min. between each set	Respiratory care	3 sets of 10 consecutive breaths with a pause of 1 min. between each set	-	-
Rizwan et al., 2012[⁴²42 Rizwan A, Jalwan J, Mukherjee S. To compare the immediate effect of deep breathing exercise and incentive spirometry on ABG after mitral valve replacement surgery. Indian J Physiother Occup Ther. 2012;6(4):12-7.]	Mitral valve replacement surgery	-	-	Flow‑oriented IS	3 sets of 10 deep breaths with 30-60 seconds to rest	Respiratory care	3 sets of 10 deep breaths with 30-60 seconds to rest	-	-
Zangerolamo et al., 2013[⁴³43 Zangerolamo TB, Barrientos TG, Baltieri L, Moreno M, Pazzianotto-Forti EM. Effects of flow-oriented incentive spirometry after myocardial revascularization. Rev Bras Cardiol. 2013;26(3):180-5.]	CABG	64.3 ± 11.1	57.5 ± 10	Flow‑oriented IS	3 sets of 10 repetitions	Respiratory care	For each exercise, three sets of 10 repetitions. 3 sessions per day	-	-
Yazdannik et al., 2016[⁴⁴44 Yazdannik A, Bollbanabad HM, Mirmohammadsadeghi M, Khalifezade A. The effect of incentive spirometry on arterial blood gases after coronary artery bypass surgery (CABG). Iran J Nurs Midwifery Res. 2016;21(1):89-92. doi:10.4103/1735-9066.174761. https://doi.org/10.4103/1735-9066.174761... ]	CABG	-	-	Flow‑oriented IS	10 times breathing with IS every 2 hours in the daytime for three days	Respiratory care	Only usual exercise	-	-
Manapunsopee et al., 2019[⁴⁵45 Manapunsopee S, Thanakiatpinyo T, Wongkornrat W, Chuaychoo B, Thirapatarapong W. Effectiveness of incentive spirometry on inspiratory muscle strength after coronary artery bypass graft surgery. Heart Lung Circ. 2020;29(8):1180-6. doi:10.1016/j.hlc.2019.09.009. https://doi.org/10.1016/j.hlc.2019.09.00... ]	CABG	109.0 ± 55.0	129.0 ± 57.0	Flow‑oriented IS + respiratory care	10 times per hour - slow maximal inhalations	Respiratory care	Breathing exercise 10 times per hour	-	-
Alam et al., 2020[⁴⁶46 Alam M, Hussain S, Shehzad MI, Mushtaq A, Rauf A, Ishaq S. Comparing the effect of incentive spirometry with acapella on blood gases in physiotherapy after coronary artery bypass graft. Cureus. 2020;12(2):e6851. doi:10.7759/cureus.6851. https://doi.org/10.7759/cureus.6851.... ]	CABG	-	-	IS	Breathing exercise with IS	Standard physiotherapy + Acapella	Breathing exercise + Acapella	-	-
Amin et al., 2021[⁴⁷47 Amin R, Alaparthi GK, Samuel SR, Bairapareddy KC, Raghavan H, Vaishali K. Effects of three pulmonary ventilation regimes in patients undergoing coronary artery bypass graft surgery: a randomized clinical trial. Sci Rep. 2021;11(1):6730. doi:10.1038/s41598-021-86281-4. https://doi.org/10.1038/s41598-021-86281... ]	CABG	-	-	Flow‑oriented IS	3 sets of 5 repeated deep breaths - four times a day	Volume-oriented IS	3 sets of 5 repeated deep breaths - four times in a day	Respiratory care	3 sets of 5 deep breaths - 4 times in a day
Barkhordari-Sharifabad et al., 2021[⁴⁸48 Zerang F, Amouzeshi A, Barkhordari-Sharifabad M. Comparison of the effect of incentive spirometry and deep breathing exercises on hemodynamic parameters of patients undergoing coronary artery bypass graft surgery: a clinical trial. J Vasc Nurs. 2022;40(3):134-9. doi:10.1016/j.jvn.2022.08.002. https://doi.org/10.1016/j.jvn.2022.08.00... ]	CABG	-	-	IS	10 deep breaths, every 2 hours during awakening	Respiratory care	10 times with 2-hour interval when the patient woke up	-	-

Study	Outcomes observed
	PPC (n,%)		Adverse events (n,%)		Mortality (n,%)		Length of hospital stay (days) (mean ± SD)		Length of intensive care unit stay (days) (mean ± SD)
	ISG	CG	ISG	CG	ISG	CG	ISG	CG	ISG	CG
Iverson et al., 1978a[²⁷27 Iverson LI, Ecker RR, Fox HE, May IA. A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Ann Thorac Surg. 1978;25(3):197-200. doi:10.1016/s0003-4975(10)63521-7. https://doi.org/10.1016/s0003-4975(10)63... ]	35 (60.3)^* * Atelectasis	23 (54.7)^* * Atelectasis and 1 (2.3)^ Pneumonia	0	1 (2.4)	0	1 (2.4)	-	-	-	-
Iverson et al., 1978b[²⁷27 Iverson LI, Ecker RR, Fox HE, May IA. A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Ann Thorac Surg. 1978;25(3):197-200. doi:10.1016/s0003-4975(10)63521-7. https://doi.org/10.1016/s0003-4975(10)63... ]	35 (60.3)^* * Atelectasis	18 (40)^* * Atelectasis	0	0	0	0	-	-	-	-
Gale and Sanders, 1980[²⁸28 Gale GD, Sanders DE. Incentive spirometry: its value after cardiac surgery. Can Anaesth Soc J. 1980;27(5):475-80. doi:10.1007/BF03007047. https://doi.org/10.1007/BF03007047.... ]	51 (98)^* * Atelectasis	57 (100)^* * Atelectasis	-	-	-	-	-	-	-	-
Dull and Dull, 1983[²⁹29 Dull JL, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Phys Ther. 1983;63(5):655-9. doi:10.1093/ptj/63.5.655. https://doi.org/10.1093/ptj/63.5.655.... ]	-	-	-	-	-	-	-	-	-	-
Stock et al., 1984a[²⁴24 Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, et al. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Crit Care Med. 1984;12(11):969-72. doi:10.1097/00003246-198411000-00010. https://doi.org/10.1097/00003246-1984110... ]	11 (92)^* * Atelectasis	12 (92)^* * Atelectasis	0 (0)	1 (8)	-	-	-	-	-	-
Stock et al., 1984b[²⁴24 Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, et al. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Crit Care Med. 1984;12(11):969-72. doi:10.1097/00003246-198411000-00010. https://doi.org/10.1097/00003246-1984110... ]	11 (92)^* * Atelectasis	9 (67)^* * Atelectasis	0 (0)	2 (15)	-	-	-	-	-	-
Jenkins et al., 1989a[³⁰30 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax. 1989;44(8):634-9. doi:10.1136/thx.44.8.634. https://doi.org/10.1136/thx.44.8.634.... ]	28 (74)^* * Atelectasis and 2 (5.2)^ Pneumonia	26 (74)^* * Atelectasis and 4 (11.4)^ Pneumonia	-	-	-	-	-	-	-	-
Jenkins et al., 1989b[³⁰30 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax. 1989;44(8):634-9. doi:10.1136/thx.44.8.634. https://doi.org/10.1136/thx.44.8.634.... ]	28 (74)^* * Atelectasis and 2 (5.2)^ Pneumonia	28 (75)^* * Atelectasis and 5 (13.5)^ Pneumonia	-	-	-	-	-	-	-	-
Jenkins et al., 1990a[³¹31 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. A comparison of breathing exercises, incentive spirometry and mobilisation after coronary artery surgery. Physiother Theory Pract. 1990;6:117-26. doi:10.3109/09593989009037789. https://doi.org/10.3109/0959398900903778... ]	28 (74)^* * Atelectasis and 2 (5.2)^ Pneumonia	26 (74)^* * Atelectasis and 4 (11.4)^ Pneumonia	-	-	-	-	-	-	-	-
Jenkins et al., 1990b[³¹31 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. A comparison of breathing exercises, incentive spirometry and mobilisation after coronary artery surgery. Physiother Theory Pract. 1990;6:117-26. doi:10.3109/09593989009037789. https://doi.org/10.3109/0959398900903778... ]	28 (74)^* * Atelectasis and 2 (5.2)^ Pneumonia	28 (75)^* * Atelectasis and 5 (13.5)^ Pneumonia	-	-	-	-	-	-	-	-
Oikkonen et al., 1991[³²32 Oikkonen M, Karjalainen K, Kähärä V, Kuosa R, Schavikin L. Comparison of incentive spirometry and intermittent positive pressure breathing after coronary artery bypass graft. Chest. 1991;99(1):60-5. doi:10.1378/chest.99.1.60. https://doi.org/10.1378/chest.99.1.60.... ]	21 (80.7)^* * Atelectasis	16 (61.5)^* * Atelectasis	11 (24.3)	13 (50)	-	-	-	-	-	-
Crowe and Bradley, 1997[³³33 Crowe JM, Bradley CA. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther. 1997;77(3):260-8. doi:10.1093/ptj/77.3.260. https://doi.org/10.1093/ptj/77.3.260.... ]	9 (10)^* * Atelectasis and 8 (8.9)^ Pneumonia	10 (10.5)^* * Atelectasis and 10 (10.5)^ Pneumonia	-	-	-	-	9 ± 3.1	9.7 ± 4.9	-	-
Savci et al., 2006[³⁴34 Savcı S, Sakınç S, İnce DI, Arikan H, Can Z, Buran Y, et al. Active cycle of breathing techniques and incentive spirometer in coronary artery bypass graft surgery. Fizyoter Rehabil. 2006;17(2):61-9.]	9 (30)^* * Atelectasis	10 (33.3)^* * Atelectasis	-	-	-	-	-	-	-	-
Romanini et al., 2007[³⁵35 Romanini W, Muller AP, Carvalho KA, Olandoski M, Faria-Neto JR, Mendes FL, et al. The effects of intermittent positive pressure and incentive spirometry in the postoperative of myocardial revascularization. Arq Bras Cardiol. 2007;89(2):94-9, 105-10. doi:10.1590/s0066-782x2007001400006. https://doi.org/10.1590/s0066-782x200700... ]	-	-	-	-	-	-	-	-	-	-
Renault et al., 2009[³⁶36 Renault JA, Costa-Val R, Rosseti MB, Houri Neto M. Comparison between deep breathing exercises and incentive spirometry after CABG surgery. Rev Bras Cir Cardiovasc. 2009;24(2):165-72. doi:10.1590/s0102-76382009000200012. https://doi.org/10.1590/s0102-7638200900... ]	-	-	-	-	-	-	-	-	2.61 ± 0.69	3.22 ± 1.06
Dias et al., 2011a[³⁷37 Dias CM, Vieira Rde O, Oliveira JF, Lopes AJ, Menezes SL, Guimarães FS. Three physiotherapy protocols: effects on pulmonary volumes after cardiac surgery. J Bras Pneumol. 2011;37(1):54-60. doi:10.1590/s1806-37132011000100009. https://doi.org/10.1590/s1806-3713201100... ]	-	-	0 (0)	0 (0)	-	-	-	-	-	-
Dias et al., 2011b[³⁷37 Dias CM, Vieira Rde O, Oliveira JF, Lopes AJ, Menezes SL, Guimarães FS. Three physiotherapy protocols: effects on pulmonary volumes after cardiac surgery. J Bras Pneumol. 2011;37(1):54-60. doi:10.1590/s1806-37132011000100009. https://doi.org/10.1590/s1806-3713201100... ]	-	-	0 (0)	0 (0)	-	-	-	-	-	-
El-Kader, 2011[³⁸38 El-Kader SMA. Blood gases response to different breathing modalities in phase I of cardiac rehabilitation program after coronary artery bypass graft. Eur J Gen Med. 2011;8(2):85-91. doi.org/10.29333/ejgm/82706. https://doi.org/doi.org/10.29333/ejgm/82... ]	-	-	-	-	-	-	-	-	-	-
Al-Mutairi et al., 2012a[³⁹39 Almutairi F, Fallows S, Mason-Whitehead E. Continuous positive airway pressure (cpap) had better outcomes when compared with incentive spirometry (IS) to re-open collapse alveoli after cardiac surgery: randomized study. Am J Respir Crit Care Med. 2012;185:A4869. doi:10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A4869. https://doi.org/10.1164/ajrccm-conferenc... ]	-	-	-	-	-	-	-	-	-	-
Al-Mutairi et al., 2012b1[⁴⁰40 Al-Mutairi FH, Fallows SJ, Abukhudair WA, Islam BB, Morris MM. Difference between continuous positive airway pressure via mask therapy and incentive spirometry to treat or prevent post-surgical atelectasis. Saudi Med J. 2012;33(11):1190-5.]	-	-	-	-	0 (0)	1 (2.8)	9.5 ± NR	8.7 ± NR	-	-
Al-Mutairi et al., 2012b2[⁴⁰40 Al-Mutairi FH, Fallows SJ, Abukhudair WA, Islam BB, Morris MM. Difference between continuous positive airway pressure via mask therapy and incentive spirometry to treat or prevent post-surgical atelectasis. Saudi Med J. 2012;33(11):1190-5.]	-	-	-	-	0 (0)	2 (5.6)	9.5 ± NR	9 ± NR	-	-
Mueenudheen et al., 2012[⁴¹41 Mueenudheen TP, Moiz JA, Gupta VP. A comparative study on the effects of incentive spirometry and deep breathing exercise on pulmonary functions after uncomplicated coronary artery bypass grafting surgery. Indian J Physiother Occup Ther. 2012;6(2):63-7.]	-	-	-	-	-	-	-	-	-	-
Rizwan et al., 2012[⁴²42 Rizwan A, Jalwan J, Mukherjee S. To compare the immediate effect of deep breathing exercise and incentive spirometry on ABG after mitral valve replacement surgery. Indian J Physiother Occup Ther. 2012;6(4):12-7.]	-	-	-	-	-	-	-	-	-	-
Zangerolamo et al., 2013[⁴³43 Zangerolamo TB, Barrientos TG, Baltieri L, Moreno M, Pazzianotto-Forti EM. Effects of flow-oriented incentive spirometry after myocardial revascularization. Rev Bras Cardiol. 2013;26(3):180-5.]	-	-	-	-	1 (12.5)	2 (25)	6.5 ± 1.69	8.25 ± 2.6	5 ± 1.6	6.87 ± 2.74
Yazdannik et al., 2016[⁴⁴44 Yazdannik A, Bollbanabad HM, Mirmohammadsadeghi M, Khalifezade A. The effect of incentive spirometry on arterial blood gases after coronary artery bypass surgery (CABG). Iran J Nurs Midwifery Res. 2016;21(1):89-92. doi:10.4103/1735-9066.174761. https://doi.org/10.4103/1735-9066.174761... ]	-	-	-	-	-	-	-	-	-	-
Manapunsopee et al., 2019[⁴⁵45 Manapunsopee S, Thanakiatpinyo T, Wongkornrat W, Chuaychoo B, Thirapatarapong W. Effectiveness of incentive spirometry on inspiratory muscle strength after coronary artery bypass graft surgery. Heart Lung Circ. 2020;29(8):1180-6. doi:10.1016/j.hlc.2019.09.009. https://doi.org/10.1016/j.hlc.2019.09.00... ]	3 (6.4)^* * Atelectasis and 1 (2.1)^ Pneumonia	5 (11.6)^* * Atelectasis	17 (36.2)	10 (23.2)	-	-	6.75 ± 7.77	12.5 ± 18.82	-	-
Alam et al., 2020[⁴⁶46 Alam M, Hussain S, Shehzad MI, Mushtaq A, Rauf A, Ishaq S. Comparing the effect of incentive spirometry with acapella on blood gases in physiotherapy after coronary artery bypass graft. Cureus. 2020;12(2):e6851. doi:10.7759/cureus.6851. https://doi.org/10.7759/cureus.6851.... ]	-	-	-	-	-	-	-	-	-	-
Amin et al., 2021[⁴⁷47 Amin R, Alaparthi GK, Samuel SR, Bairapareddy KC, Raghavan H, Vaishali K. Effects of three pulmonary ventilation regimes in patients undergoing coronary artery bypass graft surgery: a randomized clinical trial. Sci Rep. 2021;11(1):6730. doi:10.1038/s41598-021-86281-4. https://doi.org/10.1038/s41598-021-86281... ]	-	-	-	-	-	-	-	-	-	-
Barkhordari-Sharifabad et al., 2021[⁴⁸48 Zerang F, Amouzeshi A, Barkhordari-Sharifabad M. Comparison of the effect of incentive spirometry and deep breathing exercises on hemodynamic parameters of patients undergoing coronary artery bypass graft surgery: a clinical trial. J Vasc Nurs. 2022;40(3):134-9. doi:10.1016/j.jvn.2022.08.002. https://doi.org/10.1016/j.jvn.2022.08.00... ]	-	-	-	-	-	-	-	-	-	-

	Lung function								Oxygenation
Study	FEV1%		FVC%		PEF (L/min)		VC (%)		FEF (%)		PaO2 (mmHg)		SO2 (%)
	ISG	CG	ISG	CG	ISG	CG	ISG	CG	ISG	CG	ISG	CG	ISG	CG
Iverson et al., 1978a[²⁷27 Iverson LI, Ecker RR, Fox HE, May IA. A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Ann Thorac Surg. 1978;25(3):197-200. doi:10.1016/s0003-4975(10)63521-7. https://doi.org/10.1016/s0003-4975(10)63... ]	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Iverson et al., 1978b[²⁷27 Iverson LI, Ecker RR, Fox HE, May IA. A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Ann Thorac Surg. 1978;25(3):197-200. doi:10.1016/s0003-4975(10)63521-7. https://doi.org/10.1016/s0003-4975(10)63... ]	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Gale and Sanders, 1980[²⁸28 Gale GD, Sanders DE. Incentive spirometry: its value after cardiac surgery. Can Anaesth Soc J. 1980;27(5):475-80. doi:10.1007/BF03007047. https://doi.org/10.1007/BF03007047.... ]	-	-	-	-	-	-	1.8 ± 1.4 L	1.4 ± 1.5 L	-	-	60.6 ± 13.7	59.4 ± 12.07	-	-
Dull and Dull, 1983a[²⁹29 Dull JL, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Phys Ther. 1983;63(5):655-9. doi:10.1093/ptj/63.5.655. https://doi.org/10.1093/ptj/63.5.655.... ]	37 ± NR	40 ± NR	35 ± NR	35 ± NR	-	-	-	-	55 ± NR	70 ± NR	-	-	-	-
Dull and Dull, 1983b[²⁹29 Dull JL, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Phys Ther. 1983;63(5):655-9. doi:10.1093/ptj/63.5.655. https://doi.org/10.1093/ptj/63.5.655.... ]	37 ± NR	40 ± NR	35 ± NR	41 ± NR	-	-	-	-	55 ± NR	53 ± NR	-	-	-	-
Stock et al., 1984a[²⁴24 Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, et al. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Crit Care Med. 1984;12(11):969-72. doi:10.1097/00003246-198411000-00010. https://doi.org/10.1097/00003246-1984110... ]	0.76 ± 0.173 L	0.63 ± 0.288 L	0.96 ± 0.243 L	0.76 ± 0.324 L	-	-	-	-	-	-	93 ± 17	99 ± 21	-	-
Stock et al., 1984b[²⁴24 Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, et al. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Crit Care Med. 1984;12(11):969-72. doi:10.1097/00003246-198411000-00010. https://doi.org/10.1097/00003246-1984110... ]	0.76 ± 0.173 L	0.59 ± 0.252 L	0.96 ± 0.243 L	0.73 ± 0.283 L	-	-	-	-	-	-	93 ± 17	94 ± 17	-	-
Jenkins et al., 1989a[³⁰30 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax. 1989;44(8):634-9. doi:10.1136/thx.44.8.634. https://doi.org/10.1136/thx.44.8.634.... ]	1.8 ± 0.5 L	1.7 ± 0.4 L	2.4 ± 0.5 L	2.2 ± 0.5 L	2.55 ± 0.6	2.50 ± 0.6	-	-	-	-	60 ± 6.7	67.5 ± 7.5	-	-
Jenkins et al., 1989b[³⁰30 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax. 1989;44(8):634-9. doi:10.1136/thx.44.8.634. https://doi.org/10.1136/thx.44.8.634.... ]	1.8 ± 0.5 L	1.8 ± 0.5 L	2.4 ± 0.5 L	2.3 ± 0.6 L	2.55 ± 0.6	2.53 ± 0.67	-	-	-	-	60 ± 6.7	66.7 ± 7.5	-	-
Jenkins et al., 1990a[³¹31 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. A comparison of breathing exercises, incentive spirometry and mobilisation after coronary artery surgery. Physiother Theory Pract. 1990;6:117-26. doi:10.3109/09593989009037789. https://doi.org/10.3109/0959398900903778... ]	-	-	-	-	-	-	2.6 ± 0.1 L	2.5 ± 0.1 L	-	-	60 ± 7.5	60 ± 7.5	-	-
Jenkins et al., 1990b[³¹31 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. A comparison of breathing exercises, incentive spirometry and mobilisation after coronary artery surgery. Physiother Theory Pract. 1990;6:117-26. doi:10.3109/09593989009037789. https://doi.org/10.3109/0959398900903778... ]	-	-	-	-	-	-	2.6 ± 0.1 L	2.7 ± 0.2 L	-	-	60 ± 7.5	60 ± 7.5	-	-
Oikkonen et al., 1991[³²32 Oikkonen M, Karjalainen K, Kähärä V, Kuosa R, Schavikin L. Comparison of incentive spirometry and intermittent positive pressure breathing after coronary artery bypass graft. Chest. 1991;99(1):60-5. doi:10.1378/chest.99.1.60. https://doi.org/10.1378/chest.99.1.60.... ]	-	-	-	-	-	-	-	-	-	-	75 ± 7.5	82.5 ± 7.5	-	-
Crowe and Bradley, 1997[³³33 Crowe JM, Bradley CA. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther. 1997;77(3):260-8. doi:10.1093/ptj/77.3.260. https://doi.org/10.1093/ptj/77.3.260.... ]	81 ± 4	83 ± 4	82 ± 6	85 ± 4	-	-	-	-	-	-	-	-	90 ± NR	79 ± NR
Savci et al., 2006[³⁴34 Savcı S, Sakınç S, İnce DI, Arikan H, Can Z, Buran Y, et al. Active cycle of breathing techniques and incentive spirometer in coronary artery bypass graft surgery. Fizyoter Rehabil. 2006;17(2):61-9.]	57.26 ± 14.6	64.98 ± 12.95	57.6 ± 14.17	63.17 ± 11.65	4.54 ± 1.44	5.90 ± 1.96	53.18 ± 13.6	57.76 ± 9.47	-	-	76.08 ± 13.69	79.69 ± 18.26	95.74 ± 2.13	94.59 ± 4.33
Romanini et al., 2007[³⁵35 Romanini W, Muller AP, Carvalho KA, Olandoski M, Faria-Neto JR, Mendes FL, et al. The effects of intermittent positive pressure and incentive spirometry in the postoperative of myocardial revascularization. Arq Bras Cardiol. 2007;89(2):94-9, 105-10. doi:10.1590/s0066-782x2007001400006. https://doi.org/10.1590/s0066-782x200700... ]	-	-	-	-	-	-	-	-	-	-	-	-	91.15 ± 83.2	94.7 ± 86.4
Renault et al., 2009[³⁶36 Renault JA, Costa-Val R, Rosseti MB, Houri Neto M. Comparison between deep breathing exercises and incentive spirometry after CABG surgery. Rev Bras Cir Cardiovasc. 2009;24(2):165-72. doi:10.1590/s0102-76382009000200012. https://doi.org/10.1590/s0102-7638200900... ]	1.12 ± NR L	1.37 ± NR L	1.37 ± NR L	1.27 ± NR L	-	-	-	-	-	-	-	-	-	-
Dias et al., 2011a[³⁷37 Dias CM, Vieira Rde O, Oliveira JF, Lopes AJ, Menezes SL, Guimarães FS. Three physiotherapy protocols: effects on pulmonary volumes after cardiac surgery. J Bras Pneumol. 2011;37(1):54-60. doi:10.1590/s1806-37132011000100009. https://doi.org/10.1590/s1806-3713201100... ]	-	-	46.7 ± 52.08	51.3 ± 37.09	-	-	-	-	-	-	-	-	97.2 ± NR	97 ± NR
Dias et al., 2011b[³⁷37 Dias CM, Vieira Rde O, Oliveira JF, Lopes AJ, Menezes SL, Guimarães FS. Three physiotherapy protocols: effects on pulmonary volumes after cardiac surgery. J Bras Pneumol. 2011;37(1):54-60. doi:10.1590/s1806-37132011000100009. https://doi.org/10.1590/s1806-3713201100... ]	-	-	46.7 ± 52.08	54.3 ± 49.64	-	-	-	-	-	-	-	-	97.2 ± NR	97.7 ± NR
El-Kader, 2011a[³⁸38 El-Kader SMA. Blood gases response to different breathing modalities in phase I of cardiac rehabilitation program after coronary artery bypass graft. Eur J Gen Med. 2011;8(2):85-91. doi.org/10.29333/ejgm/82706. https://doi.org/doi.org/10.29333/ejgm/82... ]	-	-	-	-	-	-	-	-	-	-	82.91 ± 2.3	71.66 ± 4	-	-
El-Kader, 2011b[³⁸38 El-Kader SMA. Blood gases response to different breathing modalities in phase I of cardiac rehabilitation program after coronary artery bypass graft. Eur J Gen Med. 2011;8(2):85-91. doi.org/10.29333/ejgm/82706. https://doi.org/doi.org/10.29333/ejgm/82... ]	-	-	-	-	-	-	-	-	-	-	82.91 ± 2.3	74.5 ± 4.8	-	-
Al-Mutairi et al., 2012a[³⁹39 Almutairi F, Fallows S, Mason-Whitehead E. Continuous positive airway pressure (cpap) had better outcomes when compared with incentive spirometry (IS) to re-open collapse alveoli after cardiac surgery: randomized study. Am J Respir Crit Care Med. 2012;185:A4869. doi:10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A4869. https://doi.org/10.1164/ajrccm-conferenc... ]	-	-	-	-	-	-	1.59 ± 3.9 L	1.88 ± 4.6 L	-	-	-	-	96.53 ± 181.5	96.83 ± 182.1
Al-Mutairi et al., 2012b1[⁴⁰40 Al-Mutairi FH, Fallows SJ, Abukhudair WA, Islam BB, Morris MM. Difference between continuous positive airway pressure via mask therapy and incentive spirometry to treat or prevent post-surgical atelectasis. Saudi Med J. 2012;33(11):1190-5.]	-	-	-	-	-	-	-	-	-	-	-	-	95.6 ± 0.4	97.17 ± 0.43
Al-Mutairi et al., 2012b2[⁴⁰40 Al-Mutairi FH, Fallows SJ, Abukhudair WA, Islam BB, Morris MM. Difference between continuous positive airway pressure via mask therapy and incentive spirometry to treat or prevent post-surgical atelectasis. Saudi Med J. 2012;33(11):1190-5.]	-	-	-	-	-	-	-	-	-	-	-	-	95.6 ± 0.4	96 ± 0.6
Mueenudheen et al., 2012[⁴¹41 Mueenudheen TP, Moiz JA, Gupta VP. A comparative study on the effects of incentive spirometry and deep breathing exercise on pulmonary functions after uncomplicated coronary artery bypass grafting surgery. Indian J Physiother Occup Ther. 2012;6(2):63-7.]	52 ± 10	54 ± 9	46 ± 9	45 ± 8	-	-	-	-	-	-	79.77 ± 9.22	82.85 ± 10.53	-	-
Rizwan et al., 2012[⁴²42 Rizwan A, Jalwan J, Mukherjee S. To compare the immediate effect of deep breathing exercise and incentive spirometry on ABG after mitral valve replacement surgery. Indian J Physiother Occup Ther. 2012;6(4):12-7.]	-	-	-	-	-	-	-	-	-	-	76.41 ± 15.85	75.35 ± 11.55	94.72 ± 2.9	94.7 ± 1.95
Zangerolamo et al., 2013[⁴³43 Zangerolamo TB, Barrientos TG, Baltieri L, Moreno M, Pazzianotto-Forti EM. Effects of flow-oriented incentive spirometry after myocardial revascularization. Rev Bras Cardiol. 2013;26(3):180-5.]	-	-	-	-	-	-	1.68 ± 0.48 L	1.4 ± 0.4 L	-	-	-	-	-	-
Yazdannik et al., 2016[⁴⁴44 Yazdannik A, Bollbanabad HM, Mirmohammadsadeghi M, Khalifezade A. The effect of incentive spirometry on arterial blood gases after coronary artery bypass surgery (CABG). Iran J Nurs Midwifery Res. 2016;21(1):89-92. doi:10.4103/1735-9066.174761. https://doi.org/10.4103/1735-9066.174761... ]	-	-	-	-	-	-	-	-	-	-	72.7 ± 7.1	82.3 ± 4.8	96.8 ± 1.4	90.5 ± 2.1
Manapunsopee et al., 2019[⁴⁵45 Manapunsopee S, Thanakiatpinyo T, Wongkornrat W, Chuaychoo B, Thirapatarapong W. Effectiveness of incentive spirometry on inspiratory muscle strength after coronary artery bypass graft surgery. Heart Lung Circ. 2020;29(8):1180-6. doi:10.1016/j.hlc.2019.09.009. https://doi.org/10.1016/j.hlc.2019.09.00... ]	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Alam et al., 2020[⁴⁶46 Alam M, Hussain S, Shehzad MI, Mushtaq A, Rauf A, Ishaq S. Comparing the effect of incentive spirometry with acapella on blood gases in physiotherapy after coronary artery bypass graft. Cureus. 2020;12(2):e6851. doi:10.7759/cureus.6851. https://doi.org/10.7759/cureus.6851.... ]	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Amin et al., 2021a[⁴⁷47 Amin R, Alaparthi GK, Samuel SR, Bairapareddy KC, Raghavan H, Vaishali K. Effects of three pulmonary ventilation regimes in patients undergoing coronary artery bypass graft surgery: a randomized clinical trial. Sci Rep. 2021;11(1):6730. doi:10.1038/s41598-021-86281-4. https://doi.org/10.1038/s41598-021-86281... ]	0.96 ± 1.2 L	0.86 ± 1.1 L	1.10 ± 1.4 L	0.90 ± 1.1 L	1.44 ± 1.8 L	1.08 ± 1.4 L	-	-	-	-	-	-	-	-
Amin et al., 2021b[⁴⁷47 Amin R, Alaparthi GK, Samuel SR, Bairapareddy KC, Raghavan H, Vaishali K. Effects of three pulmonary ventilation regimes in patients undergoing coronary artery bypass graft surgery: a randomized clinical trial. Sci Rep. 2021;11(1):6730. doi:10.1038/s41598-021-86281-4. https://doi.org/10.1038/s41598-021-86281... ]	1.26 ± 15.2 L	0.86 ± 1.1 L	1.53 ± 1.9 L	0.90 ± 1.1 L	2.22 ± 44.7 L	1.08 ± 1.4 L	-	-	-	-	-	-	-	-
Barkhordari-Sharifabad et al., 2021[⁴⁸48 Zerang F, Amouzeshi A, Barkhordari-Sharifabad M. Comparison of the effect of incentive spirometry and deep breathing exercises on hemodynamic parameters of patients undergoing coronary artery bypass graft surgery: a clinical trial. J Vasc Nurs. 2022;40(3):134-9. doi:10.1016/j.jvn.2022.08.002. https://doi.org/10.1016/j.jvn.2022.08.00... ]	-	-	-	-	-	-	-	-	-	-	-	-	96.5 ± 1.50	95.2 ± 2.38

Study	Total score	Item 1	Item 2	Item 3	Item 4	Item 5	Item 6	Item 7	Item 8	Item 9	Item 10	Item 11
Iverson et al., 1978[²⁷27 Iverson LI, Ecker RR, Fox HE, May IA. A comparative study of IPPB, the incentive spirometer, and blow bottles: the prevention of atelectasis following cardiac surgery. Ann Thorac Surg. 1978;25(3):197-200. doi:10.1016/s0003-4975(10)63521-7. https://doi.org/10.1016/s0003-4975(10)63... ]	4^* * =Score assessed by authors	N	N	N	Y	N	N	N	Y	N	Y	Y
Gale and Sanders, 1980[²⁸28 Gale GD, Sanders DE. Incentive spirometry: its value after cardiac surgery. Can Anaesth Soc J. 1980;27(5):475-80. doi:10.1007/BF03007047. https://doi.org/10.1007/BF03007047.... ]	4	Y	Y	N	N	N	N	N	Y	N	Y	Y
Dull and Dull, 1983[²⁹29 Dull JL, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Phys Ther. 1983;63(5):655-9. doi:10.1093/ptj/63.5.655. https://doi.org/10.1093/ptj/63.5.655.... ]	3	N	Y	N	Y	N	N	N	N	N	Y	N
Stock et al., 1984[²⁴24 Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, et al. Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Crit Care Med. 1984;12(11):969-72. doi:10.1097/00003246-198411000-00010. https://doi.org/10.1097/00003246-1984110... ]	5	N	Y	N	Y	N	N	N	Y	N	Y	Y
Jenkins et al., 1989[³⁰30 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax. 1989;44(8):634-9. doi:10.1136/thx.44.8.634. https://doi.org/10.1136/thx.44.8.634.... ]	5	Y	Y	N	Y	N	N	Y	N	N	Y	Y
Jenkins et al., 1990[³¹31 Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. A comparison of breathing exercises, incentive spirometry and mobilisation after coronary artery surgery. Physiother Theory Pract. 1990;6:117-26. doi:10.3109/09593989009037789. https://doi.org/10.3109/0959398900903778... ]	4	Y	Y	N	Y	N	N	N	N	N	Y	Y
Oikkonen et al., 1991[³²32 Oikkonen M, Karjalainen K, Kähärä V, Kuosa R, Schavikin L. Comparison of incentive spirometry and intermittent positive pressure breathing after coronary artery bypass graft. Chest. 1991;99(1):60-5. doi:10.1378/chest.99.1.60. https://doi.org/10.1378/chest.99.1.60.... ]	6	Y	Y	N	Y	N	N	Y	Y	N	Y	Y
Crowe and Bradley, 1997[³³33 Crowe JM, Bradley CA. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther. 1997;77(3):260-8. doi:10.1093/ptj/77.3.260. https://doi.org/10.1093/ptj/77.3.260.... ]	6	Y	Y	N	Y	N	N	Y	Y	N	Y	Y
Savci et al., 2006[³⁴34 Savcı S, Sakınç S, İnce DI, Arikan H, Can Z, Buran Y, et al. Active cycle of breathing techniques and incentive spirometer in coronary artery bypass graft surgery. Fizyoter Rehabil. 2006;17(2):61-9.]	6	Y	Y	N	Y	N	N	Y	Y	N	Y	Y
Romanini et al., 2007[³⁵35 Romanini W, Muller AP, Carvalho KA, Olandoski M, Faria-Neto JR, Mendes FL, et al. The effects of intermittent positive pressure and incentive spirometry in the postoperative of myocardial revascularization. Arq Bras Cardiol. 2007;89(2):94-9, 105-10. doi:10.1590/s0066-782x2007001400006. https://doi.org/10.1590/s0066-782x200700... ]	4	N	Y	N	Y	N	N	N	N	N	Y	Y
Renault et al., 2009[³⁶36 Renault JA, Costa-Val R, Rosseti MB, Houri Neto M. Comparison between deep breathing exercises and incentive spirometry after CABG surgery. Rev Bras Cir Cardiovasc. 2009;24(2):165-72. doi:10.1590/s0102-76382009000200012. https://doi.org/10.1590/s0102-7638200900... ]	2	Y	N	N	Y	N	N	N	N	N	Y	N
Dias et al., 2011[³⁷37 Dias CM, Vieira Rde O, Oliveira JF, Lopes AJ, Menezes SL, Guimarães FS. Three physiotherapy protocols: effects on pulmonary volumes after cardiac surgery. J Bras Pneumol. 2011;37(1):54-60. doi:10.1590/s1806-37132011000100009. https://doi.org/10.1590/s1806-3713201100... ]	4	Y	Y	N	Y	N	N	N	N	N	Y	Y
El-Kader, 2011[³⁸38 El-Kader SMA. Blood gases response to different breathing modalities in phase I of cardiac rehabilitation program after coronary artery bypass graft. Eur J Gen Med. 2011;8(2):85-91. doi.org/10.29333/ejgm/82706. https://doi.org/doi.org/10.29333/ejgm/82... ]	5	N	Y	N	Y	N	N	N	Y	N	Y	Y
Al-Mutairi et al., 2012a[³⁹39 Almutairi F, Fallows S, Mason-Whitehead E. Continuous positive airway pressure (cpap) had better outcomes when compared with incentive spirometry (IS) to re-open collapse alveoli after cardiac surgery: randomized study. Am J Respir Crit Care Med. 2012;185:A4869. doi:10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A4869. https://doi.org/10.1164/ajrccm-conferenc... ]	5^* * =Score assessed by authors	Y	Y	N	Y	N	N	N	Y	N	Y	Y
Al-Mutairi et al., 2012b[⁴⁰40 Al-Mutairi FH, Fallows SJ, Abukhudair WA, Islam BB, Morris MM. Difference between continuous positive airway pressure via mask therapy and incentive spirometry to treat or prevent post-surgical atelectasis. Saudi Med J. 2012;33(11):1190-5.]	4	Y	Y	N	N	N	N	N	Y	N	Y	Y
Mueenudheen et al., 2012[⁴¹41 Mueenudheen TP, Moiz JA, Gupta VP. A comparative study on the effects of incentive spirometry and deep breathing exercise on pulmonary functions after uncomplicated coronary artery bypass grafting surgery. Indian J Physiother Occup Ther. 2012;6(2):63-7.]	4	Y	Y	N	Y	N	N	N	N	N	Y	Y
Rizwan et al., 2012[⁴²42 Rizwan A, Jalwan J, Mukherjee S. To compare the immediate effect of deep breathing exercise and incentive spirometry on ABG after mitral valve replacement surgery. Indian J Physiother Occup Ther. 2012;6(4):12-7.]	4^* * =Score assessed by authors	Y	Y	N	Y	N	N	N	N	N	Y	Y
Zangerolamo et al., 2013[⁴³43 Zangerolamo TB, Barrientos TG, Baltieri L, Moreno M, Pazzianotto-Forti EM. Effects of flow-oriented incentive spirometry after myocardial revascularization. Rev Bras Cardiol. 2013;26(3):180-5.]	4^* * =Score assessed by authors	Y	Y	N	Y	N	N	N	N	N	Y	Y
Yazdannik et al., 2016[⁴⁴44 Yazdannik A, Bollbanabad HM, Mirmohammadsadeghi M, Khalifezade A. The effect of incentive spirometry on arterial blood gases after coronary artery bypass surgery (CABG). Iran J Nurs Midwifery Res. 2016;21(1):89-92. doi:10.4103/1735-9066.174761. https://doi.org/10.4103/1735-9066.174761... ]	4^* * =Score assessed by authors	Y	Y	N	Y	N	N	N	N	N	Y	Y
Manapunsopee et al., 2019[⁴⁵45 Manapunsopee S, Thanakiatpinyo T, Wongkornrat W, Chuaychoo B, Thirapatarapong W. Effectiveness of incentive spirometry on inspiratory muscle strength after coronary artery bypass graft surgery. Heart Lung Circ. 2020;29(8):1180-6. doi:10.1016/j.hlc.2019.09.009. https://doi.org/10.1016/j.hlc.2019.09.00... ]	7	Y	Y	Y	Y	N	N	Y	N	Y	Y	Y
Alam et al., 2020[⁴⁶46 Alam M, Hussain S, Shehzad MI, Mushtaq A, Rauf A, Ishaq S. Comparing the effect of incentive spirometry with acapella on blood gases in physiotherapy after coronary artery bypass graft. Cureus. 2020;12(2):e6851. doi:10.7759/cureus.6851. https://doi.org/10.7759/cureus.6851.... ]	3	Y	Y	N	N	N	N	N	N	N	Y	Y
Amin et al., 2021[⁴⁷47 Amin R, Alaparthi GK, Samuel SR, Bairapareddy KC, Raghavan H, Vaishali K. Effects of three pulmonary ventilation regimes in patients undergoing coronary artery bypass graft surgery: a randomized clinical trial. Sci Rep. 2021;11(1):6730. doi:10.1038/s41598-021-86281-4. https://doi.org/10.1038/s41598-021-86281... ]	5^* * =Score assessed by authors	Y	Y	N	Y	N	N	N	Y	N	Y	Y
Barkhordari-Sharifabad et al., 2021[⁴⁸48 Zerang F, Amouzeshi A, Barkhordari-Sharifabad M. Comparison of the effect of incentive spirometry and deep breathing exercises on hemodynamic parameters of patients undergoing coronary artery bypass graft surgery: a clinical trial. J Vasc Nurs. 2022;40(3):134-9. doi:10.1016/j.jvn.2022.08.002. https://doi.org/10.1016/j.jvn.2022.08.00... ]	5^* * =Score assessed by authors	Y	Y	N	Y	N	N	N	Y	N	Y	Y

14.08.2020

Medical Literature Analysis and Retrieval System Online (or MEDLINE®) via PubMed® - 175 results

#1 ("Cardiac Surgical Procedures"[Mesh]) OR "Heart Surg^*" OR "Cardiac Surg^*" OR "Cardiovascular Surg^*" OR ("Coronary Artery Bypass"[Mesh]) OR (Coronary Artery Bypass Grafting) OR CABG OR (Heart Bypass) OR (Coronary Bypass) OR (Aortocoronary Bypass) OR ("Myocardial Revascularization"[Mesh]) OR (Transmyocardial Revascularization) OR (Heart Myectomy) OR (Heart Myotomy) OR ("Cardiopulmonary Bypass"[Mesh]) OR (Heart-Lung Bypass) OR (Cardiology Robotic Surgery) OR ("Angioplasty"[Mesh]) OR ("Balloon Valvuloplasty"[Mesh]) OR (Valve Repair) OR (Valvular Surgery) OR (Valve Surgery) OR ("Cardiac Valve Annuloplasty"[Mesh]) OR Annuloplasty OR (Cardiac Valve Annulus Repair) OR (Heart Valve Annulus Repair) OR (Cardiac Valve Annular Reduction) OR (Cardiac Valve Annulus Shortening) OR (Cardiac Valve Annulus Reduction) OR (Valve Replacement) OR ("Transcatheter Aortic Valve Replacement"[Mesh]) OR TAVR OR ("Heart Valve Prosthesis Implantation"[Mesh]) OR (Insertion of Pacemaker) OR (Insertion of implantable cardioverter defibrillator) OR (Maze Surgery) OR (Aortic Aneurysm Repair) OR (Aortic Surgery) OR ("Heart Transplantation"[Mesh]) OR "Heart Transplant^*" OR (Heart Grafting) OR "Cardiac Transplant^*" OR (Insertion of Ventricular Assist Device) OR (VAD Surgery) OR (Insertion of Total Artificial Heart) OR ("Thoracic Surgery"[Mesh]) OR ("Thoracic Surgical Procedures"[Mesh]) OR "Thoracic Surg^*" OR (Arrhythmia Surgery) OR (Left Ventricular Remodeling) OR (Surgical Ventricular Restoration) OR (Atrial Fibrillation Ablation) OR (Atrial Fibrillation Surgery) OR (Hypertrophic Cardiomyopathy Surgery) OR (Thoracoscopic Surgical Procedures) OR (Thoracoscopic Surgeries) OR ("Thoracotomy"[Mesh]) OR Thoracotomies OR Thoracostomy OR ("Thoracic Surgery, Video-Assisted"[Mesh]) OR (Video-Assisted Thoracic Surgery) OR VATS

#2 ("Breathing Exercises"[Mesh]) OR "Incentive Spiromet^*" OR (Flow-Incentive Spirometer) OR Triflo OR Triflow OR Voldyne OR respiron

#3 ((((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials as topic[MeSH Terms] OR clinical trial[Publication Type] OR random^*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading])))

#4 #1 AND #2 AND #3

Embase® via Elsevier - 304 results

#1 'heart surgery'/exp OR 'heart surg^*' OR 'cardiac surg^*' OR 'cardiosurgery' OR 'heart operation' OR 'myocardial resection' OR 'surgery, heart' OR 'open heart surgery'/exp OR 'intracardiac surgery' OR 'minimally invasive cardiac surgery'/exp OR 'coronary artery bypass graft'/exp OR 'coronary artery bypass' OR 'aorta coronary artery bypass' OR 'aorta coronary bypass' OR 'aorta coronary vein bypass' OR 'aorta coronary vein shunt' OR 'aortic coronary artery bypass' OR 'aortic coronary bypass' OR 'aorticocoronary anastomosis' OR 'aorto coronary artery bypass' OR 'aorto coronary bypass' OR 'aorto coronary vein bypass' OR 'aortocoronary anastomosis' OR 'aortocoronary artery bypass' OR 'aortocoronary artery bypass' OR 'aortocoronary bypass' OR 'aortocoronary shunt' OR 'aortocoronary vein bypass' OR 'aortocoronary venous bypass' OR 'coronary artery graft' OR 'coronary bypass' OR 'coronary vein bypass' OR 'coronary venous bypass' OR 'heart muscle revascularization'/exp OR 'heart muscle revascularization' OR 'heart muscle revascularisation' OR 'anastomosis, internal mammary artery' OR 'artery implantation, mammary' OR 'implantation, internal mammary artery' OR 'internal mammary arterial anastomosis' OR 'internal mammary arterial implantation' OR 'internal mammary artery anastomosis' OR 'internal mammary artery graft' OR 'internal mammary artery implant' OR 'internal mammary artery implantation' OR 'internal mammary artery reimplantation' OR 'internal mammary-coronary artery anastomosis' OR 'mammary arterial implantation' OR 'mammary artery implantation' OR 'cardiac muscle revascularisation' OR 'cardiac muscle revascularization' OR 'myocardium revascularization' OR 'myocardium revascularisation' OR 'coronary revascularisation' OR 'coronary revascularization' OR 'heart revascularisation' OR 'heart revascularization' OR 'myocardial revascularisation' OR 'myocardial revascularization' OR 'revascularisation, transmyocardial laser' OR 'revascularization, transmyocardial laser' OR 'transmyocardial laser revascularisation' OR 'transmyocardial laser revascularization' OR 'vineberg operation' OR 'cardiopulmonary bypass'/exp OR 'cardiopulmonary bypass' OR 'atriopulmonary shunt' OR 'bypass, cardiopulmonary' OR 'cardiopulmonary shunt' OR 'heart lung bypass' OR 'angioplasty'/exp OR 'angioplasty' OR 'transluminal coronary angioplasty'/exp OR 'coronary artery dilatation, transluminal' OR p.t.c.a. OR ptca OR 'transluminal valvuloplasty'/exp OR 'transluminal valvuloplasty' OR 'balloon valvotomy' OR valvuloplasty OR valvulotomy OR 'valve repair' OR valvotomy OR valvulotomy OR 'annuloplasty'/exp OR annuloplasty OR 'heart valve replacement'/exp OR 'valve replacement' OR 'valvular replacement' OR 'valve implantation' OR 'valve prosthesis implantation' OR 'valvular replacement' OR 'transcatheter aortic valve implantation'/exp OR TAVI OR 'pacemaker implantation'/exp OR 'pacemaker implantation' OR 'artificial heart pacemaker implantation' OR 'heart pacemaker implantation' OR 'maze procedure'/exp OR 'maze procedure' OR 'Cox maze operation' OR 'Cox maze procedure' OR 'Cox maze surgery' OR 'Cox-maze ablation' OR 'Cox-maze technique' OR 'maze ablation' OR 'maze operation' OR

'maze surgery' OR 'maze technique' OR 'surgical Cox-maze procedure' OR 'surgical maze' OR 'aortic aneurysm surgery'/exp OR 'aortic aneurysm surgery' OR 'aortic surgery'/exp OR 'aortic surgery' OR 'aorta surgery' OR 'aortopexy' OR 'surgery, aorta' OR 'heart transplantation'/exp OR 'heart transplant^*' OR 'cardiac transplant^*' OR 'heart allograft' OR 'heart allotransplantation' OR 'heart heterograft' OR 'transplant, heart' OR 'heart heterotransplantation' OR 'heart homograft' OR 'heart homotransplantation' OR 'heart orthotopic transplantation' OR 'heart tissue transplantation' OR 'heart ventricle transplantation' OR 'heart graft'/exp OR 'heart graft' OR 'cardiac graft' OR 'graft, heart' OR 'Ventricular Assist Device Surg^*' OR 'Insertion of Total Artificial Heart' OR 'thorax surgery'/exp OR 'thorax surg^*' OR 'cardiothoracic surg^*' OR 'chest surg^*' OR 'chest wall surg^*' OR 'surgery, chest' OR 'surgery, thoracic' OR 'surgery, thorax' OR 'thoracic operation' OR 'thoracic surg^*' OR 'left ventricular remodeling'/exp OR 'left ventricular remodeling' OR 'surgical ventricular restoration'/exp OR 'surgical ventricular restoration' OR 'atrial fibrillation ablation'/exp OR 'atrial fibrillation ablation' OR 'thoracoscopic surgery'/exp OR 'thoracoscopic surg^*' OR 'thoracotomy'/exp OR thoracotomy OR 'video assisted thoracoscopic surgery'/exp OR 'video assisted thoracoscopic surg^*'

#2 'breathing exercise'/exp OR 'breathing exercise' OR 'incentive spirometry'/exp OR 'incentive spiromet^*' OR 'incentive spirometer'/exp OR 'Respiflo 5000' OR Coach OR Triflo OR Triflow OR Voldyne OR respiron

#3 'crossover procedure':de OR 'double-blind procedure':de OR 'randomized controlled trial':de OR 'single-blind procedure':de OR (random^* OR factorial^* OR crossover^* OR cross NEXT/1 over^* OR placebo^* OR doubl^* NEAR/1 blind^* OR singl^* NEAR/1 blind^* OR assign^* OR allocat^* OR volunteer^*):de,ab,ti

#4 #1 AND #2 AND #3

Cochrane Central Register of Controlled Trials (or CENTRAL) via Cochrane Library - 136 results

#1 MeSH descriptor: [Cardiac Surgical Procedures] explode all trees

#2 MeSH descriptor: [Coronary Artery Bypass] explode all trees

#3 MeSH descriptor: [Myocardial Revascularization] explode all trees

#4 MeSH descriptor: [Cardiopulmonary Bypass] explode all trees

#5 MeSH descriptor: [Angioplasty] explode all trees

#6 MeSH descriptor: [Balloon Valvuloplasty] explode all trees

#7 MeSH descriptor: [Cardiac Valve Annuloplasty] explode all trees

#8 MeSH descriptor: [Transcatheter Aortic Valve Replacement] explode all trees

#9 MeSH descriptor: [Heart Valve Prosthesis Implantation] explode all trees

#10 MeSH descriptor: [Heart Transplantation] explode all trees

#11 MeSH descriptor: [Thoracic Surgical Procedures] explode all trees

#12 MeSH descriptor: [Thoracotomy] explode all trees

#13 MeSH descriptor: [Thoracic Surgery, Video-Assisted] explode all trees

#14 MeSH descriptor: [Thoracic Surgery] explode all trees

#15 "Heart Surg^*" OR "Cardiac Surg^*" OR "Cardiovascular Surg^*" OR (Coronary Artery Bypass Grafting) OR CABG OR (Heart Bypass) OR (Coronary Bypass) OR (Aortocoronary Bypass) OR (Myocardial Revascularization) OR (Transmyocardial Revascularization) OR (Heart Myectomy) OR (Heart Myotomy) OR (Heart-Lung Bypass) OR (Cardiology Robotic Surgery) OR (Valve Repair) OR (Valvular Surgery) OR (Valve Surgery) OR Annuloplasty OR (Cardiac Valve Annulus Repair) OR (Heart Valve Annulus Repair) OR (Cardiac Valve Annular Reduction) OR (Cardiac Valve Annulus Shortening) OR (Cardiac Valve Annulus Reduction) OR (Valve Replacement) OR TAVR OR (Insertion of Pacemaker) OR (Insertion of implantable cardioverter defibrillator) OR (Maze Surgery) OR (Aortic Aneurysm Repair) OR (Aortic Surgery) OR "Heart Transplant^*" OR (Heart Grafting) OR "Cardiac Transplant^*" OR (Insertion of Ventricular Assist Device) OR (VAD Surgery) OR (Insertion of Total Artificial Heart) OR "Thoracic Surg^*" OR (Arrhythmia Surgery) OR (Left Ventricular Remodeling) OR (Surgical Ventricular Restoration) OR (Atrial Fibrillation Ablation) OR (Atrial Fibrillation Surgery) OR (Hypertrophic Cardiomyopathy Surgery) OR (Thoracoscopic Surgical Procedures) OR (Thoracoscopic Surgeries) OR Thoracotomies OR Thoracostomy OR (Video-Assisted Thoracic Surgery) OR VATS

#16 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15

#17 MeSH descriptor: [Breathing Exercises] explode all trees

#18 Incentive Spirometr^* OR (Flow-Incentive Spirometer) OR Coach OR Triflo OR Triflow OR Voldyne OR respiron

#19 #17 OR #18

#20 #16 AND #19

Latin American and Caribbean Health Sciences Literature (LILACS) via Virtual Health Library Regional Portal - 46 results

#1 MH:"Procedimentos Cirúrgicos Cardíacos" OR (Cardiac Surgical Procedures) OR (Procedimientos Quirúrgicos Cardíacos) OR MH:E04.100.376$ OR MH:E04.928.220$ OR MH:"Ponte de Artéria Coronária" OR (Coronary Artery Bypass) OR (Puente de Arteria Coronaria) OR (Derivação da Artéria Coronária) OR (Ponte Aortocoronária) OR MH:E04.100.376.719.332$ OR MH:E04.100.814.868.750$ OR MH:E04.928.220.520.220$ OR MH:"Ponte Cardiopulmonar" OR (Cardiopulmonary Bypass) OR (Puente Cardiopulmonar) OR (Circuito Cardiopulmonar) OR (Derivação Cardiopulmonar) OR (Ponte Coração-Pulmão) OR MH:E04.292.413$ OR MH:Angioplastia OR Angioplasty OR MH:E02.148.050 OR MH:E04.100.814.529.124$ OR MH:E04.502.382.124$ OR MH:E05.157.016$ OR MH:"Valvuloplastia com Balão" OR Valvuloplasty OR Valvuloplastia OR MH:E02.148.108$ OR MH:E05.157.125$ OR MH:"Anuloplastia da Valva Cardíaca" OR (Cardiac Valve Annuloplasty) OR (Anuloplastia de la Válvula Cardíaca) OR (Anuloplastia Valvar Cardíaca) OR (Anuloplastia da Válvula Cardíaca) OR MH:E04.100.376.062$ OR MH:E04.928.220.109$ OR MH:"Substituição da Valva Aórtica Transcateter" OR (Transcatheter Aortic Valve Replacement) OR (Reemplazo de la Válvula Aórtica Transcatéter) OR MH:E04.100.376.485.500$ OR MH:E04.650.410.500$ OR MH:E04.928.220.410.500$ OR MH:"Implante de Prótese de Valva Cardíaca" OR (Heart Valve Prosthesis Implantation) OR (Implantación de Prótesis de Válvulas Cardíacas) OR (Implantação de Prótese Valvar Cardíaca) OR (Implantação de Prótese de Valva) OR (Implantação de Prótese de Valva Cardíaca) OR (Implante de Prótese Valvar Cardíaca) OR (Implante de Prótese de Valva) OR MH:E04.100.376.485$ OR MH:E04.650.410$ OR MH:E04.928.220.410$ OR MH:"Transplante de Coração" OR (Heart Transplantation) OR (Trasplante de Corazón) OR (Enxerto Cardíaco) OR (Enxerto de Coração) OR (Transplantação Cardíaco) OR (Transplantação de Coração) OR (Transplante Cardíaco) OR MH:E04.100.376.475$ OR MH:E04.928.220.390$ OR MH:E04.936.450.475$ OR MH:"Procedimentos Cirúrgicos Torácicos" OR (Thoracic Surgical Procedures) OR (Procedimientos Quirúrgicos Torácicos) MH:E04.928$ OR MH:Toracotomia OR Thoracotomy OR Toracotomía OR MH:E04.928.760$ OR MH:"Cirurgia Torácica Vídeoassistida" OR MH:"Thoracic Surgery, Video-Assisted" OR (Cirugía Torácica Asistida por Video) OR CTVA OR VATS OR MH:E01.370.388.250.840.830$ OR MH:E01.370.388.250.950.830$ OR MH:E04.502.250.840.830$ OR MH:E04.502.250.950.830$ OR MH:E04.928.752.830$

#2 MH:"Exercícios Respiratórios" OR (Breathing Exercises) OR (Ejercicios Respiratorios) OR (Exercício Respiratório) OR (Exercícios para os Músculos Respiratórios) OR MH:E02.190.525.186$ OR MH:E02.779.474.124$ OR (Espirometria de incentivo) OR Voldyne OR Triflo OR Triflow

Filter: LILACS

PEDro - 1^st search - 47 results / 2^nd search - 81 results

#1 Heart Surg^* / Subdiscipline: Cardiothoracics / Therapy: Respiratory Therapy / Method: Clinical trial

#2 Cardiac Surg^* / Subdiscipline: Cardiothoracics / Therapy: Respiratory Therapy / Method: Clinical trial

Cumulative Index of Nursing and Allied Health (or CINAHL®) via EBSCO - 80 results

S1 (MM "Surgery, Cardiovascular+") OR (MM "Thoracic Surgery, Video-Assisted") OR (MM "Thoracic Surgery+") OR (MM "Coronary Artery Bypass+") OR (MM "Myocardial Revascularization+") OR (MM "Angioplasty, Transluminal, Percutaneous Coronary") OR (MM "Cardiopulmonary Bypass") OR (MM "Angioplasty+") OR (MM "Angioplasty, Balloon, Laser-Assisted") OR (MM "Angioplasty, Balloon+") OR (MM "Angioplasty, Laser+") OR (MM "Percutaneous Coronary Intervention") OR (MM "Balloon Dilatation+") OR (MM "Cardiac Valve Annuloplasty+") OR (MM "Mitral Valve Annuloplasty") OR (MM "Transcatheter Aortic Valve Implantation") OR (MM "Heart Valve Prosthesis") OR (MM "Heart Transplantation+") OR (MM "Heart-Lung Transplantation") OR (MM "Thoracotomy") OR (MM "Thoracostomy+")

S2 "Heart Surg^*" OR "Cardiac Surg^*" OR "Cardiovascular Surg^*" OR (Coronary Artery Bypass Grafting) OR CABG OR (Heart Bypass) OR (Coronary Bypass) OR (Aortocoronary Bypass) OR (Myocardial Revascularization) OR (Transmyocardial Revascularization) OR (Heart Myectomy) OR (Heart Myotomy) OR (Heart-Lung Bypass) OR (Cardiology Robotic Surgery) OR (Valve Repair) OR (Valvular Surgery) OR (Valve Surgery) OR Annuloplasty OR (Cardiac Valve Annulus Repair) OR (Heart Valve Annulus Repair) OR (Cardiac Valve Annular Reduction) OR (Cardiac Valve Annulus Shortening) OR (Cardiac Valve Annulus Reduction) OR (Valve Replacement) OR TAVR OR (Insertion of Pacemaker) OR (Insertion of implantable cardioverter defibrillator) OR (Maze Surgery) OR (Aortic Aneurysm Repair) OR (Aortic Surgery) OR "Heart Transplant^*" OR (Heart Grafting) OR "Cardiac Transplant^*" OR (Insertion of Ventricular Assist Device) OR (VAD Surgery) OR (Insertion of Total Artificial Heart) OR "Thoracic Surg^*" OR (Arrhythmia Surgery) OR (Left Ventricular Remodeling) OR (Surgical Ventricular Restoration) OR (Atrial Fibrillation Ablation) OR (Atrial Fibrillation Surgery) OR (Hypertrophic Cardiomyopathy Surgery) OR (Thoracoscopic Surgical Procedures) OR (Thoracoscopic Surgeries) OR Thoracotomies OR Thoracostomy OR (Video-Assisted Thoracic Surgery) OR VATS

S3 S1 OR S2

S4 (MM "Breathing Exercises+")

S5 "Incentive Spiromet^*" OR (Flow-Incentive Spirometer) OR Triflo OR Triflow OR Voldyne OR respiron

S6 S4 OR S5

S7 S3 AND S6

S8 TX allocat^* random^* OR (MH "Quantitative Studies") OR (MH "Placebos") OR TX placebo^* OR TX random^* allocat^* OR (MH "Random Assignment") OR TX randomi^* control^* trial^* OR TX ((singl^* n1 blind^*) OR (singl^* n1 mask^*) ) OR TX ( (doubl^* n1 blind^*) OR (doubl^* n1 mask^*) ) OR TX ( (tripl^* n1 blind^*) OR (tripl^* n1 mask^*) ) OR TX ( (trebl^* n1 blind^*) OR (trebl^* n1 mask^*) ) OR TX clinic^* n1 trial^* OR PT Clinical trial OR (MH "Clinical Trials+")

S9 S7 AND S9

Scopus® via Elsevier - 810 results

#1 TITLE-ABS-KEY("Cardiac Surgi^*" OR "Coronary Artery Bypass" "Myocardial Revascularization" OR "Cardiopulmonary Bypass" OR Angioplasty "Balloon Valvuloplasty" OR "Cardiac Valve Annuloplasty" OR "Transcatheter Aortic Valve Replacement" "Heart Valve Prosthesis Implantation" OR "Heart Transplant^*" OR "Thoracic Surg^*")

#2 "Heart Surg^*" OR "Cardiac Surg^*" OR "Cardiovascular Surg^*" OR "Coronary Artery Bypass Graf^*" OR CABG OR "Heart Bypass" OR "Coronary Bypass" OR "Aortocoronary Bypass" OR "Myocardial Revascularization" OR "Transmyocardial Revascularization" OR "Heart Myectomy" OR "Heart Myotomy" OR "Heart-Lung Bypass" OR "Cardiology Robotic Surg^*" OR "Valve Repair" OR "Valvular Surg^*" OR "Valve Surg^*" OR Annuloplasty OR "Cardiac Valve Annulus Repair" OR "Heart Valve Annulus Repair" OR "Cardiac Valve Annular Reduction" OR "Cardiac Valve Annulus Shortening" OR "Cardiac Valve Annulus Reduction" OR "Valve Replacement" OR TAVR OR "Insertion of Pacemaker" OR "Insertion of implantable cardioverter defibrillator" OR "Maze Surg^*" OR "Aortic Aneurysm Repair" OR "Aortic Surg^*" OR "Heart Transplant^*" OR "Heart Graft^*" OR "Cardiac Transplant^*" OR "Insertion of Ventricular Assist Device" OR "VAD Surg^*" OR "Insertion of Total Artificial Heart" OR "Thoracic Surg^*" OR "Arrhythmia Surg^*" OR "Left Ventricular Remodeling" OR "Surgical Ventricular Restoration" OR "Atrial Fibrillation Ablation" OR "Atrial Fibrillation Surg^*" OR "Hypertrophic Cardiomyopathy Surg^*" OR "Thoracoscopic Surg^*" OR Thoracotom^* OR Thoracostomy OR "Video-Assisted Thoracic Surg^*" OR VATS

#3 #1 OR #2

#4 TITLE-ABS-KEY("Breathing Exercis^*")

#5 "Incentive Spirometr^*" OR (Flow-Incentive Spirometer) OR Coach OR Triflo OR Triflow OR Voldyne OR respiron

#6 #4 OR #5

#7 #3 AND #6

#8 TITLE-ABS-KEY((clinic^* w/1 trial^*) OR (randomi^* w/1 control^*) OR (randomi^* w/2 trial^*) OR (random^* w/1 assign^*) OR (random^* w/1 allocat^*) OR (control^* w/1 clinic^*) OR (control^* w/1 trial) OR placebo^* OR (Quantitat^* w/1 Stud^*) OR (control^* w/1 stud^*) OR (randomi^* w/1 stud^*) OR (singl^* w/1 blind^*) OR (singl^* w/1 mask^*) OR (doubl^* w/1 blind^*) OR (doubl^* w/1 mask^*) OR (tripl^* w/1 blind^*) OR (tripl^* w/1 mask^*) OR (trebl^* w/1 blind^*) OR (trebl^* w/1 mask^*)) AND NOT (SRCTYPE(b) OR SRCTYPE(k) OR SRCTYPE(p) OR SRCTYPE(r) OR SRCTYPE(d) OR DOCTYPE(ab) OR DOCTYPE(bk) OR DOCTYPE(ch) OR DOCTYPE(bz) OR DOCTYPE(cr) OR DOCTYPE(ed) OR DOCTYPE(er) OR DOCTYPE(le) OR DOCTYPE(no) OR DOCTYPE(pr) OR DOCTYPE(rp) OR DOCTYPE(re) OR DOCTYPE(sh))

#9 #7 AND #8

SciELO - 1^st search - 3 results / 2^nd search - 4 results

#1 (Heart Surg^*) AND (Incentive Spiromet^*)

#2 (Cardiac Surg^*) AND (Incentive Spiromet^*)

OpenGrey Database - 0 results

Incentive Spiromet^*

ClinicalTrials.gov - 6 results

Condition: (Cardiac Surg^*) OR (Heart Surg^*) OR (Thoracic Surg^*)

Other terms: (Breathing Exercis^*) OR (Incentive Spiromet^*) OR (Flow-Incentive Spirometer) OR Triflo OR Triflow OR Voldyne OR respiron

clinicaltrialsregister.eu - 0 results

#1 Incentive Spiromet^*

Rebec - 0 results

#1 Cardiac Surg^*

#2 Heart Surg^*

World Health Organization International Clinical Trials Registry Platform - No access at the time of search.

#1 (Heart Surg^*) AND (Incentive Spiromet^*)

#2 (Cardiac Surg^*) AND (Incentive Spiromet^*)

Question 1: Incentive spirometry vs. respiratory care in patients undergoing cardiac surgery.

Question 2: Incentive spirometry vs. other therapies in patients undergoing cardiac surgery.

Question 3: Incentive spirometry vs. noninvasive ventilation in patients undergoing cardiac surgery.

Certainty assessment

No. of patients

Effect

Certainty

Importance

No. of studies

Study design

Risk of bias

Inconsistency

Indirectness

Imprecision

Other considerations

Incentive spirometry

Control

Relative (95% CI)

Absolute (95% CI)

IS vs. Respiratory care - Postoperative pulmonary complications (assessed with: number of events [pneumonia and atelectasis] recorded)

4

Randomized trials

^*Very
serious^a,b,c,d

Not
serious

Not serious

None

45/189 (24.2%)

65/203 (32.0%)

RR 0.91 (0.72 to 1.14)

29 fewer per 1,000 (from 90 fewer to 45 more)

⨁⨁◯◯
Low

Critical

IS vs. Respiratory care - LOS (assessed with: number of days spent in hospital)

3

Randomized trials

^*Very
serious^a,b,c,d,j

Not
serious

^*Seriousⁱ

None

145

146

-

MD 1.38 lower (2.96 lower to 0.21 higher)

⨁◯◯◯
Very low

Important

IS vs. Respiratory care - Length of ICU stay (assessed with: number of days spend in ICU)

2

Randomized trials

^*Very
serious^b,c,e,f,g,h

Not
serious

^*Seriousⁱ

None

26

-

MD 0.78 lower (1.61 lower to 0.06 higher)

⨁◯◯◯
Very low

Critical

IS vs. Respiratory care - Peak of expiratory flow (assessed with: spirometry [L/min])

2

Randomized trials

^*Very s
erious^b,c,e,f

Not
serious

^*Seriousⁱ

None

49

65

-

MD 0.59 lower (1.97 lower to 0.78 higher)

⨁◯◯◯
Very low

Important

IS vs. Respiratory care - Forced expiratory volume in one second (assessed with: spirometry [% and liters])

5

Randomized trials

^*Very
serious^b,c,e,f

Not
serious

Not serious

None

203

200

-

SMD 0.16 SD lower (0.48 lower to 0.16 higher)

⨁⨁◯◯
Low

Important

IS vs. Respiratory care - Forced vital capacity (assessed with: spirometry [% and liters])

5

Randomized trials

^*Very
serious^b,c,e,f

^*Serious^k

Not
serious

Not serious

None

203

200

-

SMD 0.14 SD higher (0.4 lower to 0.67 higher)

⨁◯◯◯
Very low

Important

IS vs. Respiratory care - Vital capacity (assessed with: spirometry [% and liters])

3

Randomized trials

^*Very serious^b,c,e,f,j,l

^*Serious^k

Not serious

None

57

73

-

SMD 0.38 SD higher (0.59 lower to 1.34 higher)

⨁◯◯◯
Very low

Important

IS vs. Respiratory care - Arterial oxygen partial pressure (mmHg)

6

Randomized trials

^*Very
serious^b,c,e,f,j,l

^*Serious^k

Not
serious

Not serious

None

125

157

-

MD 4.48 lower (8.32 lower to 0.63 lower)

⨁◯◯◯
Very low

Critical

IS vs. Respiratory care - Oxygen saturation (%)

3

Randomized trials

^*Very
serious^b,c,e,f,j,l

^*Serious^k

Not
serious

Not serious

None

71

-

MD 2.54 higher (1.74 lower to 6.82 higher)

⨁◯◯◯
Very low

Critical

IS vs. Other therapies - Postoperative pulmonary complications (assessed with: number of events [pneumonia and atelectasis] recorded)

3

Randomized trials

^*Very
serious^b,c,e,f,l

^*Serious^k

Not
serious

Not serious

None

38/54 (70.4%)

63/95 (66.3%)

RR 1.04 (0.73 to 1.49)

27 more per 1,000 (from 179 fewer to 325 more)

⨁◯◯◯
Very low

Critical

IS vs. Other therapies - Forced expiratory volume in one second (assessed with: spirometry [liters])

2

Randomized trials

^*Very
serious^b,c,e,f

Not
serious

^*Seriousⁱ

None

25

50

-

MD 0.08 higher (0.08 lower to 0.25 higher)

⨁◯◯◯
Very low

Important

IS vs. Other therapies - Forced vital capacity (assessed with: spirometry [% and liters])

3

Randomized trials

^*Very
serious^b,c,e,f,j,l

Not
serious

^*Seriousⁱ

None

37

73

-

SMD 0.15 SD higher (0.25 lower to 0.55 higher)

⨁◯◯◯
Very low

Important

IS vs. Other therapies - Arterial oxygen partial pressure (mmHg)

3

Randomized trials

^*Very
serious^b,c,e,f,j,l

^*Serious^k

Not
serious

Not serious

None

44

87

-

MD 3.63 lower (9.18 lower to 1.93 higher)

⨁◯◯◯
Very low

Critical

IS vs. NIV - Postoperative pulmonary complications (assessed with: number of events [pneumonia and atelectasis] recorded)

4

Randomized trials

^*Very
serious^b,c,e,f,l

^*Serious^k

Not
serious

Not serious

None

95/113 (84.1%)

106/138 (76.8%)

"RR 1.14
(0.84 to 1.55)"

108 more per 1,000 (from 123 fewer to 422 more)

⨁◯◯◯
Very low

Critical

IS vs. NIV - Mortality (assessed with: number of events recorded)

2

Randomized trials

^*Very
serious^b,c,e,f,h

Not
serious

^*Seriousⁱ

None

0/65 (0.0%)

4/114 (3.5%)

RR 0.49 (0.08 to 2.93)

18 fewer per 1,000 (from 32 fewer to 68 more)

⨁◯◯◯
Very low

Critical

IS vs. NIV - Adverse events (assessed with: number of events recorded)

3

Randomized trials

^*Very
serious^b,c,e,f,l

Not
serious

^*Seriousⁱ

None

13/61 (21.3%)

14/81 (17.3%)

RR 1.10 (0.62 to 1.95)

17 more per 1,000 (from 66 fewer to 164 more)

⨁◯◯◯
Very low

Critical

IS vs. NIV - Arterial oxygen partial pressure (mmHg)

4

Randomized trials

^*Very
serious^b,c,e,f,l

^*Serious^k

Not
serious

Not serious

None

96

120

-

MD 2.95 higher (4.69 lower to 10.58 higher)

⨁◯◯◯
Very low

Critical

IS vs. NIV - Oxygen saturation (%)

2

Randomized trials

^*Very
serious^b,c,e,f,h

^*Serious^k

Not
serious

Not serious

None

56

92

-

MD 0.99 lower (2.12 lower to 0.14 higher)

⨁◯◯◯
Very low

Critical

[1] Correspondence Address: Elinaldo da Conceição dos Santos, https://orcid.org/0000-0002-4039-2980, Department of Biological and Health Sciences, Universidade Federal do Amapá, Rodovia Josmar Chaves Pinto, S/N, Jardim Marco Zero, Macapá, AP, Brazil, Zip Code: 68902-280, E-mail: drelinaldo@yahoo.com.br

Brasil

Brasil

Is Incentive Spirometry Superior to Standard Care in Postoperative Cardiac Surgery on Clinical Outcomes and Length of Hospital and Intensive Care Unit Stay? A Systematic Review with Meta-Analysis

ABSTRACT

Introduction:

Methods:

Results:

Conclusions: