1. PICO PRESENTATION
Chelsey Giovanni

2. PICO: Is the use of an incentive spirometer preoperatively more effective that postoperative use. Purpose: To determine through evidence based research the time frame in which an incentive spirometer is most effective.

3. Search Results:
Search Words: Incentive spirometer, incentive spirometry, deep breathing, complications, surgery, post-surgical, pneumonia
Search engines: CINAHL, PubMed, Google Scholar
Results:
From the search articles relating to complications from various surgeries resulted

4. Research Articles
Kocacas, A, K Karat, G Ozgur, H Sonmezt, and R Burgut. "Value of preoperative spirometry to predict postoperative pulmonary complications." Respiratory Medicine 90.1 (1996): Print.
Valkenet, K., Trappenburg, J., Gosselink, R., Sosef, M., Willms, J., Rosman, C., & Pieters, H. (2014, April). Preoperative inspiratory muscle training to prevent postoperative pulmonary complications in patients undergoing esophageal resection (PREPARE Study): study protocol for a randomized controlled trial. Trials, 15(1), 1-9. doi: /

5. Rationale
The rationale for selecting these articles is that the articles compared the effectiveness use of the incentive spirometer and also compared the effectiveness of the exercises if done before the surgery takes place or after.
The articles compared the effectiveness of the incentive spirometer to deep breathing and it also compared the prevention of complications if the incentive spirometer was used preoperatively and postoperatively.
The articles also investigated other risk factors that could lead to pulmonary complications and the ability to prevent these complications

6. Study #1- Value of preoperative spirometry to predict post operative pulmonary complications
Sixty adult patients were selected to be part of this study, 24 women and 36 men with an average age of 48 years.
The purpose of the study was to determine the occurrence of postoperative pulmonary complications and the effectiveness of preoperative spirometry in predicting pulmonary complications.
The patients were monitored through sputum cultures, ECG, chest radiography, spirometry and blood gas analysis.
These same tests were monitored for 15 days after the surgery and spirometry was preformed in the sitting position 3 times daily

7. Why it’s important
The results of this study were important because from the information gathered it was shown that the postoperative pulmonary complication rate in patients with abnormal preoperative spirometry was higher than that of patients with normal preoperative spirometry
With this information health care providers could make a care plan taking into account the patients high risks of having complications also these patients could be monitored more closely.
Of the nine patients diagnosed with bronchitis postoperatively, seven were smokers, one had preoperative respiratory symptoms (cough for 5 yr), seven had abnormal physical findings and seven had abnormal spirometry this information is important because these patients can be labeled as high risk before surgery.

8. Study #2- Preoperative inspiratory muscle training to prevent postoperative pulmonary complications in patients undergoing esophageal resection (PREPARE Study): study protocol for a randomized controlled trial.
Single blind multicenter randomized control study
The purpose of the study was to determine if the use of the incentive spirometer is more effective when used before the surgery occurs as well as after as opposed to just after the surgery.
The patients were randomized to either participate in usual care or they were selected to preform inspiratory excises twice daily for 7 days a week for two weeks before the surgery.
Preoperative inspiratory muscle training to prevent postoperative pulmonary complications in patients undergoing esophageal resection (PREPARE Study): study protocol for a randomized controlled trial.
The the method of the study was a blind multicenter randomized control study which means that the people being study are randomly assigned to different methods of treatment
For this study there was 248 patients over the age of 18 that are undergoing esophageal resection for these patients high incidence of pneumonia has a large impact on post op outcomes. Mortality rates are nearly 20% higher for patients that experience pneumonia following the surgery.

9. Why it’s important
For patients undergoing esophageal resection, post operative pneumonia is the most frequently occurring complication.
The results of the study determined that preoperative use of the incentive spirometer reduced the amount of postoperative pneumonia by 50%
It would be important to determine for the other 50% if they were not using the spirometer as direct, other barriers

10. Ethical Considerations
The ethical considerations for the first study reviewed is that the patients would need to give their consent to be part of the study. This is different than the second article since the research that was conduct was a blind study.
It is important ethically that neither of these studies caused harmed to the participants whether the participant is part of the control population or not.
It is also ethically responsible to report the findings of the research accurately, since these results are calling for a change in policy of incentive spirometry.
The first study also questioned a specific cohort of smokers it would be important to not be judgmental or biasis

11. Credibility of the Studies
While both studies were credible there are many variables that could effect the outcome of the data; age, gender, type of surgery, presurgical history, efficacy, etc. are all factors that could change the results of the data.
To make the information in the studies more credible in their findings more research could be conducted varying the surgery types and the patients willingness to participate to collect more information.

12. Relevance
The findings of the research are relevant to practice because incentive spirometers are widely used in the hospital as an important part of postoperative care.
The findings are important because through evidenced based research it has been found that the use of incentive spirometry preoperatively as well as post operatively is more effective in preventing pulmonary complications.

13. Communication
The information gathered through this evidenced based research would need to be communicated at the all levels; individual, policy, stand of care level and professional level.
Changes would need to be communicated so that information can be given to the patient at a pre- surgical consultation
The information would need to be communicated at all levels because changes would need to be made on several levels.
Changes at the policy level would need to be changed so that policy on the use of incentive spirometer only postsurgical could be changed
They also need to be changed at the stand of care level since the new standard through evidenced based research is the use of the incentive spirometer is pre and post surgical
At the professional level new printed teaching materials and patient teaching would need to be implimented

14. Implications
The implications of this research should lead to the implementation of incentive spirometry before surgery
The would be able to be implemented for scheduled procedures but would have limitations in emergency surgeries.
There also could be limitations based on the patients cognitive level, age, place the patient resides and level of support.
Quality of care could be improved with provider teaching and materials to practice incentive spirometry before surgery.

15. Barriers
While the use of the incentive spirometer pre and post surgical showed a decrease in the incidence of pulmonary complications by 50%, this number is largely based of the efficacy of the patient.
The RN will be able to provide instructions and materials for the use of the IS but it would be up to the patient to follow those instructions for the two week period before they were to undergo surgery.
An additional PICO question from this research would be: Is the use of the incentive spirometer one weeks before surgery as effective as the use of the spirometer two weeks prior to surgery.
Another barrier of the study was that the information was gathered on only esophageal patients there have no been many studies on the use of the incentive spirometer for patients undergoing different procedures.

16. Conclusion
From the research the importance of the use of the incentive spirometer was enforced, however the use of the spirometer pre-surgically has been shown to lead to less complications and implementation and teachings on preoperative spirometry may be valuable to patients undergoing a surgical procedure