1. INCENTIVE SPIROMETRY USE FOLLOWING ABDOMINAL SURGERY James Barry, BS Stacy Marsden, MA Jill Stewart, MBA MSN Clinical Nurse Leader Program, College of Nursing Georgia Regents University

2. Background Abdominal surgery is associated with high risk of post- operative pulmonary complications (PPC) Without a therapeutic respiratory regimen, up to 25% of abdominal surgery patients develop PPC (Deodhar, 1991) Post-operative pulmonary complications include: Respiratory failure Atelectasis Pneumonia Bronchospasm Tracheobronchitis Incentive spirometry (IS) and deep-breathing exercises (DBE) can reduce the risk for PPC

3. Purpose The literature review was performed to answer the question, “For post-operative abdominal surgery patients does the use of an incentive spirometer reduce the risk of pulmonary complications compared with a regimen of deep breathing exercises?” Determining whether IS or DBE use is more effective could play a significant role in the reduction of morbidity and mortality, improving health outcomes, and reducing health costs following abdominal surgery.

4. Literature Search Strategy Databases searched: CINAHL, Cochrane, Google Scholar, Medline, Ovid Key search terms: deep breathing exercises, incentive spirometry, pulmonary complications, post abdominal surgery, Target population: adult patients at risk for pulmonary complications following abdominal surgery Inclusion criteria: studies that compare the effectiveness of DBE versus IS use in the prevention of PPCs in adults Exclusion criteria: pediatric studies, pre-surgical interventions, non-abdominal surgery Articles: 20 articles reviewed, nine articles selected ranging from 1984-2011 (paucity of studies in the last five years)

5. Results: Table 1 Interventionn/NPercentageStudy Incentive Spirometry (IS) Alone 35/231 7/21 5/20 8/20 15% 33% 25% 40% Hall, 2006 Celli, 1984 O’Conner, 1988 Sweiger, 1986 Deep Breathing Exercises (DBEx) Alone 8/76 11%Hall, 2006 Mixed IS and DBEx 28/225 12%Hall, 2006 No treatment 17/19 9/20 6/20 89% 45% 30% Celli, 1984 O’Conner, 1988 Sweiger, 1986

6. Results: Figure 1 - Risk Ratio

7. Evidence Hierarchy Level of Evidence Type of StudyAuthor 1aSystematic ReviewCarvahlo, Paisani, & Lunardi (2011) 1bRCTCelli, Rodriguez, & Snider (1984) 3bCase-controlledDeodhar, Mohite, Shirahatti, & Joshi (1991) 1bRCTGuimaraes, El Dib, Smith & Matos (2009) 1aRCTHall, J. C., Tarala, Tapper & Hall, J.L (1996) 1aRCTO’Connor, Tattersall, & Carter (1988) 1aRCTSchweiger, Gamulin, Forster, Meyer, Gemperle, & Suter (1986) 1aSystematic ReviewThomas & McIntosh (1994) Legend: 1a=systematic review of RCTs, 1b=indiv. RCTs, 2a=systematic rev. of cohort studies, 2b=indiv. Cohort studies & poor RCTS, 3a=systematic rev. of case-control studies, 3b=indiv. case-controlled studies, 4=poor quality case-controlled and cohort studies, 5=expert opinion based on clinical experience

8. Limitations Inconsistencies across studies in the definition of PPCs, methodology of data analysis Effectiveness of IS and DBE depends on patient selection, treatment dosage, instructions given, supervision during respiratory training, and patient adherence Tidal volumes not measured in all studies Not all trials are randomized The short follow-up period for most patients limits analysis of IS effectiveness The incidence of PPCs varies dramatically depending on the type of surgery and patient’s health status

9. Recommendations for Practice Continuation of current practice is recommended based on analysis of available evidence Implementation of either IS use or DBE following abdominal surgery Incentive spirometry Hourly during waking hours with 10 maximal breaths per session Deep breathing exercises 4 to 5 times daily during waking hours

10. Barriers to Implementation Barriers Requires education and supervision Ineffective unless performed as instructed Time and cost involved Patient adherence Patient health status and level of consciousness (LOC) Suggestion to overcome barriers Nurse and patient education Incorporation of IS implementation during hourly rounding Supervision for adherence and proper use Family member assistance Keep IS in patient’s line of sight

11. Conclusion IS and/or DBE are more effective than no respiratory therapy in the prevention of PPCs There is no evidence to support a statistically significant difference between IS use and DBE for the prevention of PPCs in post-operative abdominal surgery patients Additional research with adequate methodological designs is needed to clarify the effect and to justify the use of IS over DBE

12. References Carvalho, C., Paisani, D.M., & Lunardi, A.C. (2011). Incentive spirometry in major surgeries: a systematic review. Brazilian Journal of Physical Therapy, 15, 343-350. Celli, B.R., Rodriguez, K., & Snider, G.L. (1984). A controlled trial of intermittent positive pressure breathing incentive spirometry and deep breathing exercises in preventing pulmonary complications after abdominal surgery. The American Review of Respiratory Disease, 130, 12-5. Deodhar, S.D., Mohite, J.D., Shirahatti, R.G., & Joshi, S. (1991). Pulmonary complications of upper abdominal surgery. J Postgrad Med, 37, 88-92. Guimaraes, M.M., El Dib, R., Smith, R.F., & Matos, D. (2009). Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database System Rev, 3. doi: 10.1002/14651858.CD006058.pub2. Hall, J.C., Tarala, R.A., Tapper, J., & Hall, J.L. (1996). "Prevention of respiratory complications after abdominal surgery: A randomised clinical trial." BMJ, 312(7024), 148-152.

13. References National Guideline Clearinghouse. (2011). Incentive spirometry: 2011. Retrieved from http://www.guidelines.gov/content.aspx?id=34793. O'Connor, M., Tattersall, M.P., & Carter, J.A. (1988). An evaluation of the incentive spirometer to improve lung function after cholecystectomy. Anaesthesia, 43(9), 785-7. Schwieger, I., Gamulin, Z., Forster, A., Meyer, P., Gemperle, M., & Suter, P.M. (1986). Absence of benefit of incentive spirometry in low-risk patients undergoing elective cholecystectomy. A controlled randomized study. Chest, 89(5), 652-6. Thomas, J. A., & McIntosh, J.M. (1994). Are incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery? A systematic overview and meta-analysis. Physical Therapy, 74(1), 3-10.