Incentive spirometry in major surgeries: a systematic review

Incentivador respiratório em cirurgias de grande porte: uma revisão sistemática

Incentive spirometry in major surgeries: a systematic review

Incentivador respiratório em cirurgias de grande porte: uma revisão sistemática

Celso R. F. Carvalho; Denise M. Paisani; Adriana C. Lunardi

Physical Therapy Department, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil

^{Correspondence to}

ABSTRACT

OBJECTIVE: To conduct a systematic review to evaluate the evidence of the use of incentive spirometry (IS) for the prevention of postoperative pulmonary complications and for the recovery of pulmonary function in patients undergoing abdominal, cardiac and thoracic surgeries.

METHODS: Searches were performed in the following databases: Medline, Embase, Web of Science, PEDro and Scopus to select randomized controlled trials which the IS was used in pre- and/or post-operative in order to prevent postoperative pulmonary complications and/or recover lung function after abdominal, cardiac and thoracic surgery. Two reviewers independently assessed all studies. In addition, the studies quality was assessed using the PEDro scale.

RESULTS: Thirty studies were included (14 abdominal, 13 cardiac and 3 thoracic surgery; n=3,370 patients). In the analysis of the methodological quality, studies achieved a PEDro average score of 5.6, 4.7 and 4.8 points in abdominal, cardiac and thoracic surgeries, respectively. Five studies (3 abdominal, 1 cardiac and 1 thoracic surgery) compared the effect of the IS with control group (no intervention) and no difference was detected in the evaluated outcomes.

CONCLUSION: There was no evidence to support the use of incentive spirometry in the management of surgical patients. Despite this, the use of incentive spirometry remains widely used without standardization in clinical practice.

Key words: incentive spirometry; surgery; postoperative care; postoperative complication; physical therapy; breathing exercise.

RESUMO

OBJETIVO: Realizar um levantamento da literatura para avaliar as evidências do uso do incentivador respiratório (IR) na prevenção de complicações pulmonares pós-operatórias (CPPs) e recuperação da função pulmonar em pacientes submetidos a cirurgias abdominal, cardíaca e torácica.

MÉTODOS: Esta revisão sistemática utilizou as bases de dados Medline, Embase, Web of Science, PEDro e Scopus para selecionar ensaios clínicos randomizados, nos quais o IR foi utilizado nos período pré e/ou pós-operatório, visando prevenir CPP e/ou recuperar função pulmonar após cirurgias abdominal, cardíaca ou torácica. Dois revisores analisaram independentemente os estudos. Além disso, a qualidade dos estudos foi avaliada segundo a escala PEDro.

RESULTADOS: Trinta estudos foram incluídos (14 de cirurgia abdominal, 13 de cardíaca e três de torácica; n=3370 pacientes). Na análise de qualidade, os estudos obtiveram média de 5,6, 4,7 e 4,8 pontos nas cirurgias abdominais, cardíacas e torácicas, respectivamente. Cinco estudos (três de cirurgia abdominal, um de cardíaca e um de torácica) compararam o efeito do IR com grupo controle (sem intervenção) e não se verificou diferença nos desfechos estudados.

CONCLUSÃO: Não se encontraram evidências que subsidiem o uso do IR no manejo de pacientes cirúrgicos. Apesar disso, o uso do IR continua não-padronizado e amplamente difundido na prática clínica.

Palavras-chave: incentivador respiratório; cirurgia; cuidado pós-operatório; complicação pós-operatória; fisioterapia; exercício respiratório.

Introduction

Postoperative pulmonary complications (PPC) present high rates of morbidity, mortality, increase hospital costs and prolonged hospital stay predominantly in abdominal, cardiac and thoracic surgery^1-3. The incidence of PPC varies according to the previous diagnosis of the candidates for surgery; the type of surgery and the definition of PPC⁴. For all these reasons, the incidence rates vary dramatically, ranging from 2 to 40%^4-6. Atelectasis, pneumonia, tracheobronchitis, bronchospasm, exacerbation of chronic obstructive pulmonary disease, acute respiratory failure and prolonged mechanical ventilation (longer than 48 hours) can be classified as PPCs^1,7,8. However, most of the studies have considered as PPCs those conditions that present clinical repercussions, such as pneumonia and acute respiratory failure, as they increase postoperative morbidity and mortality^9-11. The major causes of PPCs may be related to shallow breathings and monotonous tidal volume in post-operative patients¹². However, other causes such as anesthesia, opioid analgesia, and postoperative pain also seem to contribute to this ventilation pattern without spontaneous deep breaths that occurs every 5 or 10 minutes¹³.

As a result, physical therapy techniques of lung re-expansion have been recommended as strategies to prevent and/or to treat the PPCs, as well as to recover the ventilatory function in the postoperative period^1,4,14,15. Techniques such as deep inspiration (DI), incentive spirometry (IS) and positive airway pressure exercises stimulate the generation of a large and sustained increase in the transpulmonary pressure, with consequent expansion of collapsed alveolar units in order to prevent and/or to treat the PPCs¹⁶. The IS has been widely used in clinical practice¹⁷, especially in the management of patients in the pre and post-operative period of major surgeries⁸, due to its low cost, ease of application and good adherence of patients to the method¹⁸.

On the other hand, the evidence supporting the use of such equipment to reduce postoperative pulmonary complications are not yet established, and there are controversies about the effectiveness in the prevention and/or in the treatment of PPCs in abdominal^19,20, cardiac²¹ and thoracic²² surgery. Systematic reviews on this topic have already been published several years ago^19-22, and it becomes necessary to update this literature to establish the efficacy of IS in the prevention of PPCs in the early recovery of lung volumes and also in the reduction of hospital stay after abdominal, cardiac and thoracic surgery.

Therefore, the objective of this study was to conduct a systematic review to evaluate the quality of the evidence on use of IS in the prevention of PPCs and in the recovery of pulmonary function in patients undergoing cardiac, thoracic and/or abdominal surgery.

Methods

Inclusion criteria

Randomized controlled trials where the IS was used in the pre and/or postoperative care aiming to prevent the incidence of PPCs in patients undergoing elective abdominal, cardiac or thoracic surgery were included in the present study. Narrative reviews, retrospective studies, non-controlled studies, personal communications, case reports, or studies that have assessed the use of the IS for training inspiratory musculature were excluded.

Clinical outcomes

Studies that have evaluated the following outcomes were considered eligible for inclusion in this study: pneumonia, atelectasis, pulmonary function, oxygenation and hospital stay length followed-up of for at least two days of postoperative care.

Search strategy and study selection

Searchers were conducted in the following databases: Medline, Embase, Web of Science, PEDro and Scopus and included studies published until up June 1^st, 2011. The search terms used were: "incentive spirometry", "breathing exercise", "chest physical therapy", "respiratory therapy," "abdominal surgery", "cardiac surgery" and "thoracic surgery". A second search was performed scanning the references lists from the studies identified in the first search, in order to identify additional studies that have not been identified in the first search. Were considered studies published in English, Portuguese and Spanish languages.

Two independent reviewers analyzed the abstracts and contents of all the studies identified in the electronic search. Both reviewers extracted the data and the agreement between them was verified. Discrepancies in data extraction were resolved by consensus. Then, studies that met all inclusion criteria were selected, using a standardized form¹⁹ which analyzed the following data:

Study assessment methods: hypothesis and study design, patient allocation procedures, length of treatment and follow-up period, primary outcome assessments, statistical analysis and representativeness of the sample as well as the presence of bias.

Participants: inclusion and exclusion criteria, age, gender, presence of comorbidities, type of surgery and other risk factors for PPCs.

Intervention: type, duration and frequency of the intervention, length and number of sessions.

Outcomes: definitions used in each study and statistical differences of the groups studied.

Studies quality criteria

After inclusion and analysis of the retrieved studies, the reviewers assessed their quality using the PEDro (Physiotherapy Evidence Database) scale. The PEDro scores ranges from 0 to 10 according to the following criteria: eligibility and source of patients, random allocation of the participants, concealed allocation, baseline comparability between the groups with regards to the most important prognostic indicators, blinding of participants, blinding of the therapists who administered the therapy, blinding of the assessor who measured the outcomes, measurements of outcomes were obtained from more than 85% of the participants included in the study, intention-to-treat analysis, description of the between-group statistical comparisons, provides both point measures and measures of variability for the outcomes²³.

Results

Studies quality criteria

Studies selection

From 250 selected studies, only 112 were considered to be included in this study. During the abstracts screening, 51 studies were excluded, being 21 reviews, 3 letters to the editors, 2 guidelines, 2 editorials, 1 congress summary, 2 questionnaires, 1 of pediatric field, 6 published in other language, 3 with non-surgical patients, 3 studies used the IS for distinct goal than those considered for this review, and 7 that have not evaluated the outcomes of interest (Figure 1).

Thirty studies published between 1974 and 2011 were included in the analysis (Tables 1 and 2) being 14 studies evaluating the effect of IS in patients undergoing abdominal surgery (n=2,153), 13 studies in patients undergoing cardiac surgery (n=1,081), 2 studies in patients undergoing thoracic surgery (n=99) and 1 study that included thoracic and abdominal surgery (n=37).

From the 14 studies included in the analysis of the effect of IS in patients undergoing abdominal surgery, 11 studies (78%) had PEDro scores >5 (Table 1). However, 12 studies (86%) did not report the sample calculation, 5 studies (36%) did not described the method of randomization, 5 studies (36%) used co-interventions, 3 studies (21%) had control group without intervention, 2 studies (15%) did not describe the definitions of the outcomes used and 2 studies (15%) did not describe the statistical analysis used. The postoperative follow-up of the included studies varied from two to ten days.

From the 13 studies included in the analysis of the effect of IS in patients undergoing cardiac surgery, 8 studies (61%) had PEDro scores >5 (Table 2); 12 studies (93%) did not report the sample calculation, 7 studies (54%) did not describe the method of randomization, 7 studies (54%) used co-intervention, 4 studies (31%) did not describe the definitions of the outcomes used and only 1 study (8%) had control group without intervention. The postoperative follow-up of the studies varied from two to 30 days. In thoracic surgery, two of the three studies evaluated had scores on PEDro scale >5 (Table 2). In addition, two studies (67%) studies did not report the sample calculation, not had control group without intervention and not used co-intervention. One study (33%) did not describe the clinical outcomes used. The postoperative follow-up of the studies varied from three to 90 days.

The effect of IS in the postoperative of abdominal surgery

PPC as an outcome

Control group without treatment vs. IS: Three studies compared the effect of IS with a control group without intervention^24,27,30, and no between-group differences were found.

Another intervention vs. IS: Eleven studies compared the effectiveness of IS with another intervention. In three of them^32,34,35 the authors showed that the use of IS reduced the incidence of PPC compared with other physical therapy interventions; six studies^{13,24-26,30,33} showed no between group differences in the incidence of PCC between IS and other intervention; and two studies^27,29 showed that IS failed to reduce the incidence of PPC when compared to exercises with positive pressure (CPAP or IPPB) (Table 3).

Lung function as an outcome

Control group without intervention vs. IS: Only one study compared the effect of IS with a control group³⁰, and no between-groups changes in lung function were observed.

Another intervention vs. IS: One study³⁶ compared the effect of IS with the "conventional physical therapy" and an early recovery of the tidal volume in patients who used IS was observed. One study³¹ compared the effect of IS with continuous positive airway pressure exercise (CPAP) and found that patients in the CPAP group presented an early increase in the lung volume compared to IS group. One study²⁸ compared the use of IS in the preoperative period vs. the use of IS in the pre and postoperative periods and found that the use of IS in the postoperative of laparoscopic surgery did not assist in the recovery of the vital capacity and forced expiratory volume in the first second (Table 3).

Six studies^{13,24-26,30,33} compared the use of IS with other interventions and found that IS had no effect in any of the outcomes investigated (Table 3). It should be emphasized that no study reported adverse effects from the use of IS.

The effect of IS in the postoperative of cardiac surgery

PPC as an outcome

Control group without intervention vs. IS: only one study compared the effects of IS with a control group without intervention⁴¹, and no between-group differences were observed.

Another intervention vs. IS: Nine studies evaluated the incidence of PPC^{37,38,40,41,44,45,47,48,51}. One study³⁸ showed that the use of IS associated to exercises with positive pressure (EPAP) reduced the incidence of PPC in patients undergoing surgery for myocardial revascularization when compared with deep breathing (Table 4). One study⁴⁸ showed that exercises with positive pressure (IPPB) reduced the incidence of PPC when compared to IS. Seven studies^{37,40,41,44,45,48} found no differences in the incidence of PPC when compared IS to another intervention.

Lung function as an outcome

Another intervention vs. IS: Eight studies evaluated the lung function as an outcome^{37,39,40,43-45,47,52}, being two studies^44,47, the IS improved the lung function when compared to other physical therapy interventions. One study³⁹ showed that the IS did not restore the lung function after surgery when compared to the use of exercises with positive pressure. One study⁴³ showed that patients who performed resisted breathing showed better recovery of lung volumes in comparison to IS (Table 4). In four studies^37,40,44,52, no differences in the improvement of lung function and in the oxygenation were observed when compared the IS to another intervention or to a control group without intervention (Table 4).

The effects of IS in the postoperative of thoracic surgery

Two studies^46,50 evaluated the effect of IS compared to a control group without intervention. In one of those⁴⁶, it was observed that patients who used the IS associated with inspiratory muscle training in the postoperative period presented an improvement in lung function when compared to a control group without intervention. In two studies^42,50, the use of IS was not better than a control group without intervention for the outcomes early postoperative recovery of oxygenation, lung function or incidence of PPC (Table 4).

Discussion

The results of the eligible studies showed that there is no evidence to support the use of IS in pre and/or post-operative care of patients undergoing abdominal, cardiac or thoracic surgery. In this systematic review, the inclusion of studies and their analysis were performed carefully, through an comprehensive search strategy and independent assessment performed by two reviewers with regards to the methodological quality of the retrieved studies in order to verify the evidence to support the wide use of IS in clinical practice. Most of the included studies have evaluated the effect of IS associated with another intervention, and the patients follow-up period was short which limits the analysis of the isolated effect of IS. Another finding of this review was the progressive reduction of the published studies designed to evaluate the effect of IS in the postoperative period. In addition, these studies also presented a small number of included patients and the sample size calculation was not presented.

Studies evaluating the effect of IS presented the same methodological quality score (PEDro≅5) independently of the surgery evaluated. It was also observed that there was no improvement in the methodological quality of studies over time. Nine (30%) included studies (three in abdominal^34-36, five in cardiac^47-52 and one⁵⁰ in thoracic surgery) presented PEDro scores below 5, and six of them showed that the use of IS favors the early recovery of lung function or the prevention of PPC. The methodological flaws found in most studies were the lack of a sample size calculation, problems in experimental design and inadequate method of randomization, and this may have generated bias in the interpretation of the results obtained by the treatment with the IS.

Analyzing only the studies^24-36 that evaluated the effect of IS in patients undergoing abdominal surgery, showed that this technique did not demonstrate to be beneficial in relation to other physical therapy interventions in the prevention of PPC. Some factors can be analyzed to justify these findings: first, the lack of consensus among physical therapists with regards to the gold standard intervention in the postoperative period, including the appropriate number of repetitions, duration of therapy and other postoperative treatments that may influence the results found. In the absence of a gold standard intervention, the studies should perhaps prioritize the experimental design that included a control group without intervention to better estimate the effects of IS, however only three studies were found with this purpose^24,27,30. Second, the IS continues to be widely used in clinical practice and recommended as prophylaxis of PPC in the recent pre-operative evaluation consensus^1,15. However, since the last conducted systematic review¹⁹, few studies were published, a fact that seems contradictory, since IS remains widely used in postoperative of abdominal surgery care even without proven evidence. Third, a large variability in the population included in the studies that evaluated the effect of IS was found, being in some studies, there were the inclusion of patients with low risk of developing PPC, few comorbidities associated, low surgical duration (less than 210 minutes) and patients underwent laparoscopic surgery (very low risk). This allows us to infer that the absence of the effect may have occurred because the use of the IS may not be necessary for all patients, but only for those at high risk and whom are most likely to develop PPC in the postoperative period. Finally, it is important to remember that there are two types of incentive spirometers, i.e. flow incentive and volume incentive, and little is known about the differences between them. Some studies^12,33,47 included in this review used a specific type of incentive spirometer (the Bartlet), which is currently considered outdated equipment and it is no longer commercially available.

With regards to cardiac surgery, no sufficient evidence for the use of IS was found. Since the last systematic review on the prevention of PPC in cardiac surgery²¹, five studies were published to evaluate the effectiveness of IS. From these studies, only one⁴¹ included a control group without intervention, and no between-group difference was found with regards to the incidence of PPC, which makes definitive conclusions about the effect of IS in these patients impossible. Most of the studies that compare the IS with another physical therapy intervention perform the exercises with a positive pressure equipment such as CPAP and Bilevel, and evaluate as an outcome the reduction of PPC or the improvement of postoperative lung function. These studies showed that patients who performed exercises with positive pressure presented a faster recovery of lung function in the postoperative period when compared to IS, however this improvement, although statistically significant, cannot be considered clinically relevant, since PPC incidence had not been evaluated. Due to the absence of a control group (without intervention), it is not possible to ensure that both the use of IS and the use of positive pressure exercises presents an improvement in relation to the absence of such therapies. Another factor that hampers the understanding of the effect of IS is the large variability found in studies regarding how to use the equipment with positive pressure. The results regarding the IS effect in patients undergoing thoracic surgery are inconclusive and, since the last systematic review, no study was been published that supports the use of IS in the postoperative period of these surgeries.

This systematic review presents some methodological limitations, such as the inclusion of only studies published in English, Portuguese and Spanish languages. Furthermore, it was not possible to contact the authors of the studies whose data were not included in the published manuscript, however, it is believed that such data were not crucial for our analysis.

Conclusion

No evidence was found that support the use of IS in the management of surgical patients, and there is an urgent need for studies with adequate methodological designs to clarify the effect and to justify the use of this technique. Nevertheless, the use of IS is still widely used among health professionals.

Acknowledgments

To the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), for the financial support.

Received: 06/07/2011

Revised: 06/28/2011

Accepted: 06/30/2011

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Publication Dates

• Publication in this collection
  14 Oct 2011
• Date of issue
  Oct 2011

History

• Reviewed
  2011
• Received
  06 July 2011
• Accepted
  2011