A Simple Adaptation for the Convenient Application of Incentive Spirometry in Tracheostomized Critically Ill Patients

How to cite this article: Arasu M, Singh AK, LaguduvaH A. A Simple Adaptation for the Convenient Application of Incentive Spirometry in Tracheostomized Critically Ill Patients. Indian J Crit Care Med 2024;28(5):520-521.

The effect of incentive spirometry in perioperative patients with lung cancer-a systematic review and meta-analysis

BACKGROUND

Incentive spirometry (IS) as a routine respiratory therapy during the perioperative period has been widely used in clinical practice. However, the impact of IS on patients with perioperative lung cancer remains controversial. This review aimed to evaluate the efficacy of IS in perioperative pulmonary rehabilitation for patients with lung cancer.

METHODS

Cochrane Library, PubMed, Web of Science, Ovid, CINAHL, Chinese National Knowledge Infrastructure, Weipu, and Wanfang Databases were searched from inception to 30 November 2023. Only randomized controlled trials were included in this systematic review. The PRISMA checklist served as the guidance for conducting this review. The quality assessment of the included studies was assessed by the Cochrane risk-of-bias tool. The meta-analysis was carried out utilizing Review Manager 5.4. Furthermore, sensitivity analysis and subgroup analysis were also performed.

RESULTS

Nine studies recruited 1209 patients met our inclusion criteria. IS combined with other respiratory therapy techniques was observed to reduce the incidence of postoperative pulmonary complications, enhance pulmonary function, curtail the length of hospital stay, and lower the Borg score. Nevertheless, no improvements were found in the six-minute walk distance or quality of life score.

CONCLUSIONS

Although IS demonstrates benefits as a component of comprehensive intervention measures for perioperative patients with lung cancer, it proves challenging to determine the precise impact of IS as a standalone component within the comprehensive intervention measures. Therefore, further researches are required to better understand the effectiveness of IS isolation and its interactions when integrated with additional respiratory therapies for these patients.

CLINICAL TRIAL REGISTRATION

PROSPERO, https://www.crd.york.ac.uk/prospero/ , registry number: CRD42022321044.

The Impact of Laparoscopic Intraperitoneal Instillation of Ropivacaine in Enhancing Respiratory Recovery and Reducing Acute Postoperative Pain in Laparoscopic Sleeve Gastrectomy: a Double-Blinded Randomised Control; RELiEVE Trial

PURPOSE

Laparoscopic intraperitoneal instillation of local anaesthetic in bariatric surgery proven to reduce postoperative pain. Limited data are available regarding the use of instillation ropivacaine and its impact on the recovery of respiratory effort. This study aims to evaluate the efficacy of laparoscopic intraperitoneal instillation of ropivacaine in reducing acute postoperative pain and enhancing the recovery of respiratory effort in laparoscopic sleeve gastrectomy.

MATERIALS AND METHODS

This double-blinded RCT enrolled 110 patients who underwent laparoscopic sleeve gastrectomy at Hospital Canselor Tuanku Muhriz UKM from November 2020 to May 2021. Any patients with previous abdominal surgery, chronic kidney disease, or liver disease were excluded. The patients were randomised into two groups: (i) the IPLA group which received ropivacaine intraperitoneal instillation at the dissected left crus and (ii) the placebo group (sterile water instillation). Perioperative analgesia was standardised. The first 24-h postoperative pain was assessed using a VAS. The respiratory effort was assessed using incentive spirometry simultaneously.

RESULTS

Total of 110 patients were recruited. The VAS score was lower with an enhanced recovery of respiratory effort in the local anaesthetic group compared to the placebo group (P < 0.05) within the first 24 h postoperatively. In addition, the placebo group required additional postoperative analgesia (P < 0.05). No side effects were reported with the use of intraperitoneal instillation of ropivacaine.

CONCLUSION

The use of intraperitoneal instillation of ropivacaine in laparoscopic sleeve gastrectomy is recommended as it is safe, effectively reduces acute postoperative pain, and enhances the recovery of respiratory effort postoperatively.

[Acute chest syndrome in adult sickle cell patients]

Sickle cell disease is a frequent genetic condition, due to a mutation of the β-globin gene, leading to the production of an abnormal S hemoglobin and characterized by multiple vaso-occlusive events. The acute chest syndrome is a severe complication associated with a significant disability and mortality. It is defined by the association of one or more clinical respiratory manifestations and a new infiltrate on lung imaging. Its pathophysiology is complex and implies vaso-occlusive phenomena (pulmonary vascular thrombosis, fat embolism), infection, and alveolar hypoventilation. S/S or S/β⁰-thalassemia genotype, a history of vaso-occlusive crisis or acute chest syndrome, a low F hemoglobin level (<5%), a high steady-state hemoglobin level (> 10 g/dL), or a high steady-state leukocytosis (>10 G/L) are the main risk factors. Febrile chest pain, dyspnea, sometimes cough with expectorations are its main clinical manifestations, and bi-basal crackles are found at auscultation. Inferior alveolar opacities with or without pleural effusions are identified on chest X-ray or CT-scan. Management of the acute chest syndrome should be prompt and implies, besides the recognition of severity signs, a multimodal analgesia, oxygen supplementation, sometimes a parenteral antibiotic treatment and the frequent use of blood transfusions especially in the most severe cases. Prevention is important and includes a regular monitoring of hospitalized patients and the use of incentive spirometry.

Tulane STAR (Sending Texts, Advancing Results): impact of text messaging on bariatric post-operative protocol compliance

BACKGROUND

Text messaging is frequently employed in the outpatient setting to communicate with or send reminders to patients. However, there is a paucity of literature on the impact of text messaging on inpatient care. In this study, the use of text messaging in hospitalized patients is evaluated by assessing patient compliance to a post-operative bariatric protocol.

METHODS

This was a randomized controlled trial that studied compliance to a post-operative bariatric protocol in patients who underwent bariatric surgery at a tertiary, academic medical center between February and May 2021. Patients were randomized to either the control group, in which they received standard post-operative education alone or the Tulane Sending Texts, Advancing Results (STAR) intervention arm, in which participants received the same post-operative education along with two text message reminders to drink water, use their incentive spirometers, and ambulate (per post-operative instructions) on post-operative day (POD) # 0 and POD # 1. The primary outcome was compliance with the protocol, defined as the number of 1-oz cups of water consumed, incentive spirometry usage, and ambulation frequency and distance. Secondary outcomes include length of stay and complications.

RESULTS

A total of 35 patients were enrolled in the study (17 control, 18 STAR intervention). There was no significant difference in age, BMI, or type of surgery performed between the two groups. Clear liquid consumption was significantly higher in the STAR intervention group with an average of 27.7 ± 3.5 cups as compared to 18.2 ± 8.9 in the control group (p < 0.001). Similarly, statistically significant increases in incentive spirometry usage (p < 0.01) and ambulation distance and frequency (p < 0.02) were observed in the STAR intervention group.

CONCLUSIONS

While patients are in the hospital, text messaging can improve compliance to post-operative protocols. Peri-operative text messaging can enhance patient education and communication.

Preoperative incentive spirometry for preventing postoperative pulmonary complications in patients undergoing coronary artery bypass graft surgery: a prospective, randomized controlled trial

BACKGROUND

Postoperative pulmonary complications (PPCs) often occur after cardiac operations and are a leading cause of morbidity, inhibit oxygenation, and increase hospital length of stay and mortality. Although clinical evidence for PPCs prevention is often unclear and crucial, measures occur to reduce PPCs. One device usually used for this reason is incentive spirometry (IS). The aim of the study is to evaluate the effect of preoperative incentive spirometry to prevent postoperative pulmonary complications, improve postoperative oxygenation, and decrease hospital stay following coronary artery bypass graft (CABG) surgery patients.

METHODS

This was a clinical randomized prospective study. A total of 80 patients were selected as candidates for CABG at An-Najah National University Hospital, Nablus-Palestine. Patients had been randomly assigned into two groups: incentive spirometry group (IS), SI performed before surgery (study group) and control group, preoperative spirometry was not performed. The 40 patients in each group received the same protocol of anesthesia and ventilation in the operating room.

RESULT

The study findings showed a significant difference between the IS and control groups in the incidence of postoperative atelectasis. There were 8 patients (20.0%) in IS group and 17 patients (42.5%) in the control group (p = 0.03). Mechanical ventilation duration was significantly less in IS group. The median was four hours versus six hours in the control group (p < 0.001). Hospital length of stay was significantly less in IS group, and the median was six days versus seven days in the control group (p < 0.001). The median of the amount of arterial blood oxygen and oxygen saturation was significantly improved in the IS group (p < 0.005).

CONCLUSION

Preoperative incentive spirometry for two days along with the exercise of deep breathing, encouraged coughing, and early ambulation following CABG are in connection with prevention and decreased incidence of atelectasis, hospital stay, mechanical ventilation duration and improved postoperative oxygenation with better pain control. A difference that can be considered both significant and clinically relevant. Trial registration Thai Clinical Trials Registry: TCTR20201020005. Registered 17 October 2020-retrospectively registered.

Contrasting effects of three breathing techniques on pulmonary function, functional capacity and daily life functional tasks in patients following valve replacement surgery- A pilot randomized clinical trial

Background

Valve replacement surgeries affect the physiological mechanisms of patients leading to various postoperative pulmonary complications. Lung expansion therapy consisting of numerous techniques is routinely used for the prevention and treatment of these complications.

Objectives

Our study aimed to compare the effects of diaphragmatic breathing (DB), flow (FS) and volume-oriented incentive spirometer (VS) in patients following valve replacement surgery.

Methods

29 patients posted valve replacement surgeries were randomly assigned to VS, FS and DB groups. Patients underwent preoperative training and seven-day rehabilitation post-surgery. Pulmonary function tests were performed before surgery and for seven days afterward. On the seventh postoperative day, patients performed a six-minute walk test and completed a functional difficulties questionnaire (FDQ).

Results

Pulmonary function test values reduced in all three groups postoperatively when compared to the preoperative values but improved by the seventh postoperative day (p < 0.05). On comparing the seventh postoperative day values to the preoperative values, the VS group had no significant difference (p = 1.00) (Forced Vital Capacity- % change: DB-37.76, VS-1.59, FS-27.98), indicating that the value had nearly returned to the baseline. As compared to the DB and FS groups, FVC showed a greater improvement in the VS group (p = 0.01 and p = 0.06 respectively). No significant differences were observed between groups for distance walked (p > 0.05), however, FDQ scores demonstrated positive changes in favor of VS when contrasted with FS or DB (p < 0.05).

Conclusion

Diaphragmatic breathing, flow or volume-oriented spirometer could improve pulmonary function in the postoperative period. The volume-oriented spirometer, however, was found to be the most beneficial among the three techniques in improving patients’ pulmonary function and daily life functional tasks. Further research is warranted to confirm these findings.

•

The present pilot randomized clinical trial is the first of a kind that exhibits the effects of three breathing exercises in patients following valve replacement cardiac surgery.

•

The study demonstrates the individual and contrasting effects of volume spirometry, volume spirometry and deep breathing exercise between preoperative day until postoperative day 7 in terms of pulmonary function and function activities.

Use of Incentive Spirometry in Adults following Cardiac, Thoracic, and Upper Abdominal Surgery to Prevent Post-Operative Pulmonary Complications: A Systematic Review and Meta-Analysis

BACKGROUND

Currently, consensus on the effectiveness of incentive spirometry (IS) following cardiac, thoracic, and upper abdominal surgery has been based on randomized controlled trials (RCTs) and systematic reviews of lower methodological quality. To improve the quality of the research and to account for the effects of IS following thoracic surgery, in addition to cardiac and upper abdominal surgery, we performed a meta-analysis with thorough application of the Grading of Recommendations Assessment, Development and Evaluation scoring system and extensive reference to the Cochrane Handbook for Systematic Reviews of Interventions.

OBJECTIVE

The objective of this study was to determine, with rigorous methodology, whether IS for adult patients (18 years of age or older) undergoing cardiac, thoracic, or upper abdominal surgery significantly reduces30-day post-operative pulmonary complications (PPCs), 30-day mortality, and length of hospital stay (LHS) when compared to other rehabilitation strategies.

METHODS

The literature was searched using Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and Web of Science for RCTs between the databases' inception and March 2019. A random-effect model was selected to calculate risk ratios (RRs) with 95% confidence intervals (CIs).

RESULTS

Thirty-one RCTs involving 3,776 adults undergoing cardiac, thoracic, or upper abdominal surgery were included. By comparing the use of IS to other chest rehabilitation strategies, we found that IS alone did not significantly reduce 30-day PPCs (RR = 1.00, 95% CI: 0.88-1.13) or 30-day mortality (RR = 0.73, 95% CI: 0.42-1.25). Likewise, there was no difference in LHS (mean difference = -0.17,95% CI: -0.65 to 0.30) between IS and the other rehabilitation strategies. None of the included trials significantly impacted the sensitivity analysis and publication bias was not detected.

CONCLUSIONS

This meta-analysis showed that IS alone likely results in little to no reduction in the number of adult patients with PPCs, in mortality, or in the LHS, following cardiac, thoracic, and upper abdominal surgery.

A kid-friendly approach to Incentive Spirometry

Incentive spirometer (IS) is a popular choice for chest physiotherapy. It is used to optimize preoperative respiratory status and prevent postoperative pulmonary complications. However, the use of conventional forms of IS pose a challenging task in children due to the lack of cooperation, compliance, and submaximal effort on the part of pediatric patients. To tackle this problem, we describe an innovative and fascinating technique of spirometry. It employs a toy as a better acceptable incentive spirometry device in pediatric population. This toy has a mouthpiece and a long inflatable plastic strip at the other end. As the child blows into the mouthpiece, a captivating sound from the toy keeps buzzing progressively till the air is being blown during exhalation and is accompanied with inflation of the strip in an elongated fashion. Hence, this device incorporates the two best enjoyed incentives for children, namely, visual and audio to ensure patient compliance and participation.

I text for I COUGH: A clinical pilot study to evaluate the impact of text messaging upon postoperative ambulation in the hospital

BACKGROUND

The "I COUGH" protocol is associated with improved postoperative pulmonary outcomes, and ambulation is an essential component. I COUGH is an acronym for Incentive spirometry, Coughing, Oral care, Understanding (patient and staff education), Getting-out-of-bed, and Head-of-bed elevation. This trial sought to enhance one component, specifically ambulation after operations.

METHODS

Randomized trial of inpatients in a safety-net, academic medical center. The intervention group received standard I COUGH education along with text message reminders to ambulate postoperatively, whereas the control group received standard education alone. Postoperative walking frequency was compared to each participant's ambulation on the day prior to enrollment.

RESULTS

The intervention group had an average improvement of 1.8 ± 1.8 walks per day per patient, while the average change for the control group was 0.2 ± 1.0 walks per day per patient. This represents a 9-fold increase in ambulation for the intervention group (p = 0.03).

CONCLUSIONS

Implementation of text message reminders increased ambulation and improved adherence to the I COUGH protocol following operations. This system should be further investigated as an adjunct to postoperative care.

ERAS protocol with respiratory prehabilitation versus conventional perioperative protocol in elective gastrectomy- a randomized controlled trial

BACKGROUND

Several studies have investigated the efficacy of enhanced recovery programs in patients undergoing gastrectomy. The role of prehabilitation in these programs has not been evaluated in this subset of patients. This study incorporated incentive spirometry as a type of respiratory prehabilitation in the Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy.

METHODS

In this single-center, prospective, open-labeled randomized controlled trial, 58 patients were randomized into two groups - a conventional perioperative care group and an ERAS group. The patients in the ERAS group received a supervised regimen of preoperative volume-oriented incentive spirometry as respiratory prehabilitation in addition to other ERAS care elements. The length of hospitalization (LOH) was assessed as the primary outcome, while the postoperative peak expiratory flow rate (PEFR) and the incidence of surgical and pulmonary complications were the secondary outcomes.

RESULTS

The patients in the ERAS group had a shorter median LOH compared to the conventional group (11 days vs 13 days, p = 0.003). The patients in the ERAS group also had smaller fall in postoperative PEFR from baseline, which was significant on the second postoperative day (p = 0.011). None of the patients were found to have anastomotic leaks. The incidence of surgical complications was comparable between the groups (p = 0.137).

CONCLUSION

ERAS protocol reduced the duration of hospitalization without increasing the complications compared to conventional perioperative protocol. Respiratory prehabilitation in the form of a supervised schedule of incentive spirometry helped in the preservation of lung functions in the postoperative period.

Is incentive spirometry beneficial for patients with lung cancer receiving video-assisted thoracic surgery?

Background

The effectiveness of Incentive spirometry (IS) in patients undergoing video-assisted thoracic surgery (VATS) remains lacking. We conducted a population-based study to investigate the effectiveness of IS on patients with lung cancers following VATS.

Methods

We identified patients newly diagnosed with lung cancer who underwent surgical resection by VATS or thoracotomy from the years 2000 to 2008 in the Longitudinal Health Insurance Database. Exposure variable was the use of IS during admission for surgical resection by VATS or thoracotomy. Primary outcomes included hospitalization cost, incidence of pneumonia, and length of hospital stay. Secondary outcomes included the frequency of emergency department (ED) visits and hospitalizations at 3-month, 6-month, and 12-month follow-ups after thoracic surgery.

Results

We analyzed 7549 patients with lung cancer undergoing surgical resection by VATS and thoracotomy. The proportion of patients who were subjected to IS was significantly higher in those who underwent thoracotomy than in those who underwent VATS (68.4% vs. 53.1%, P < 0.0001). After we controlled for potential covariates, the IS group significantly reduced hospitalization costs (− 524.5 USD, 95% confidence interval [CI] = − 982.6 USD – -66.4 USD) and the risk of pneumonia (odds ratio = 0.55, 95% CI = 0.32–0.95) compared to the non-IS group following VATS. No difference in ED visit frequency and hospitalization frequency at 3-month, 6-month, and 1-year follow-up was noted between the IS and the non-IS groups following VATS.

Conclusions

The use of IS in patients with lung cancers undergoing VATS may reduce hospitalization cost and the risk of pneumonia.

Clinical management of rib fractures and methods for prevention of pulmonary complications: A review

Rib fractures are common injuries associated with significant morbidity and mortality, largely due to pulmonary complications. Despite equivocal effectiveness data, incentive spirometers are widely utilized to reduce pulmonary complications in the postoperative setting. Few studies have evaluated the effectiveness of incentive spirometry after rib fracture. Multiple investigations have demonstrated incentive spirometry to be an important screening tool to identify high-risk rib fracture patients who could benefit from aggressive, multidisciplinary pulmonary complication prevention strategies. This review evaluates the epidemiology of rib fractures, their associated pulmonary complications, along with the evidence for optimizing their clinical management through the use of incentive spirometry, multimodal analgesia, and surgical fixation.

Patient Factors Associated with Successful Incentive Spirometry

BACKGROUND

Incentive spirometers (IS) are commonly prescribed after various surgical procedures with the intended effect of reducing postoperative pulmonary complications. Factors associated with correct use of IS by postoperative patients has not previously been studied.

METHODS

A cross-sectional analysis of postoperative patients was completed to assess whether patients knew how to correctly inhale on their IS. For each patient, the following variables were collected: whether the device was within arm's reach of the patient, if the patient reported having used their IS, if they considered the IS to be helpful, and if they felt more confident using IS after a brief educational intervention was performed by study investigators.

RESULTS

A total of 26.2% (11/42) of patients failed to use their IS correctly, and 38.1% (16/42) denied ever using the device in their postoperative care. Device location, perceived benefit, and previous use were identified as statistically significant determinants of successful use. Following a brief educational intervention by a physician, 73.8% (31/42) of patients were more confident in their ability to use IS during the remainder of their care.

DISCUSSION

A substantial portion of postoperative patients failed to correctly utilize their IS. Device proximity to the patient, patient perspectives on potential benefits of IS, and previous use of the device may affect correct use. Patient education and optimization of device placement should be considered to increase compliance during IS implementation.

Respiratory physiotherapy in intensive care unit: Bibliographic review

INTRODUCTION AND AIMS

Patients in intensive care unit are susceptible to complications due to different causes (underlying disease, immobilisation, infection risk…) The current main intervention in order to prevent these complications is respiratory physiotherapy, a common practice for nurses on a daily basis. Therefore, we decided to carry out this bibliographic review to describe the most efficient respiratory physiotherapy methods for the prevention and treatment of lung complications in patients in intensive care, taking into account the differences between intubated and non-intubated patients.

METHODOLOGY

The bibliographic narrative review was carried out on literature available in Pubmed, Cinahl and Cochrane Library. The established limits were language, evidence over the last 15 years and age.

RESULTS

Techniques involving lung expansion, cough, vibration, percussion, postural drainage, incentive inspirometry and oscillatory and non-oscillatory systems are controversial regarding their efficacy as respiratory physiotherapy methods. However, non-invasive mechanical ventilation shows clear benefits. In the case of intubated patients, manual hyperinflation and secretion aspirations are highly efficient methods for the prevention of the potential complications mentioned above. In this case, other RP methods showed no clear efficiency when used individually.

DISCUSSION AND CONCLUSIONS

Non-invasive mechanical ventilation (for non-intubated patients) and manual hyperinflation (for intubated patients) proved to be the respiratory physiotherapy methods with the best results. The other techniques are more controversial and the results are not so clear. In both types of patients this literature review suggests that combined therapy is the most efficient.

A Real-World Evidence Study Assessing the Impact of Adding the Aerobika Oscillating Positive Expiratory Pressure Device to Standard of Care Upon Healthcare Resource Utilization and Costs in Post-Operative Patients

INTRODUCTION

The aim of this real-world study was to measure the benefit of the Aerobika oscillating positive expiratory pressure (OPEP) device when added to standard of care (defined as incentive spirometry [IS]) for post-operative patients.

METHODS

Adults aged ≥ 18 years who were hospitalized for cardiac, thoracic or upper abdominal surgery between 1 September 2013 and 30 April 2017 were identified from IQVIA's Hospital Charge Detail Master (CDM) database; the index date was the date of the first hospitalization for surgery. The control cohort (IS) included patients who had ≥ 1 CDM record within 12 months prior to the index date and ≥ 1 record after discharge, evidence of IS use during index hospitalization and no evidence of use of a PEP or OPEP device at any time during the study period. The Aerobika OPEP cohort was selected in a similar manner, except that patients were required to have evidence of Aerobika OPEP use during the index hospitalization. Aerobika OPEP patients were 1:1 matched to IS patients using propensity score (PS) matching. Hospital readmissions and costs were measured at 30 days post-discharge from the index hospitalization.

RESULTS

After PS matching, 144 patients were included in each cohort. At 30 days post-discharge, compared to the control (IS) cohort there were significantly fewer patients in the Aerobika OPEP cohort with ≥ 1 all-cause re-hospitalizations (13.9 vs. 22.9%; p = 0.042). The patients in the Aerobika OPEP cohort also had a shorter mean length of stay (± standard deviation) (1.25 ± 4.04 vs. 2.60 ± 8.24 days; p = 0.047) and lower total unadjusted mean all-cause cost per patient ($3670 ± $13,894 vs. $13,775 ± $84,238; p = 0.057). Adjusted analyses suggested that hospitalization costs were 80% lower for the Aerobika OPEP cohort versus the IS cohort (p = 0.001).

CONCLUSION

Our results suggest that the addition of the Aerobika OPEP device to standard of care (IS) is beneficial in the post-operative setting.

FUNDING

Trudell Medical International.

Comparison of breathing patterns, pressure, volume, and flow characteristics of three breathing techniques to encourage lung inflation in healthy older people

Background: It is important to encourage lung inflation to prevent postsurgical pulmonary complications and we compared three breathing techniques that place different emphasis on inspiratory flow and breath-holding. Methods: Fourteen healthy older people (69 ± 3.6 yrs) used diaphragmatic breathing (DB), Triflo II (TF), and a water pressure threshold device (BreatheMAX; BM) in a randomized and balanced crossover design. Outcome measures were inspiratory flow and pressure, inspiratory time (Ti), tidal volume (Vt), and breathing frequency. Results: Inspiratory flow with TF was significantly faster than DB and BM (p < 0.001: 0.96 ± 0.1; 0.43 ± 0.20 and 0.28 ± 0.1 L.s^-1, respectively) and pressures greater (p < 0.001: -1.3 ± 0.6, -5.5 ± 1.2 and -2.8 ± 3.6 cm H₂O). However, Ti was shorter (TF, 1.16 ± 0.21s; DB, 3.31 ± 0.97 s, p < 0.001; BM, 5.53 ± 1.92 s, p < 0.001), resulting in smaller Vt (TF, 1.12 ± 0.29 L; DB, 1.28 ± 0.29L, p = 0.003; BM, 1.37 ± 0.43L, p = 0.016). Breathing frequency was faster with TF compared to DB and BM (p < 0.001). Conclusions: Substantial lung inflation could be achieved with any of the above-mentioned methods, although Vt was smaller with TF and the high inspiratory flow with this method may not inflate the lower lung. The high pressures and rapid breathing with TF could increase the sense of effort. Trials are needed to determine the clinical value of the different breathing exercises.

An Observational Study for Knowing the Compliance of Patients Scheduled for Major Abdominal and Thoracic Cancer Surgeries in a Single Specialty Center

Background:

Peri-operative incentive spirometry (IS) helps in improving pulmonary function, facilitates sputum clearance and prevents unwanted postoperative pulmonary complications after major abdominal and thoracic surgery. In our hospital, all patients are instructed to practice IS before abdominal and thoracic surgeries so that they can perform it in the postoperative period effectively. However, many patients do not follow our advice. A few unfortunate patients land up with pulmonary complications as it becomes difficult to train them after surgery.

Aims:

To determine the compliance rate of patients who were instructed to perform incentive spirometry preoperatively.

Study design and settings:

Observational, single arm study in a single speciality centre.

Materials and Methods:

After approval from hospital ethics committee the study was registered with Clinical Trials Registry of India (CTRI). 100 patients posted for major abdominal or thoracic cancer surgery were enrolled in the study. They were instructed to perform incentive spirometry(IS) in front of relatives, an information leaflet was provided to them and the spirometry effort was noted in ‘ml’. The effort was crossed checked on the day of surgery. Patients performing IS correctly with effort more or equal to that noted earlier were labelled as compliant. Others were labelled as non-compliant. The reason of non-compliance was to be determined using a questionnaire meant for patient and the accompanying family member.

Results:

Out of 100, 26 patients were found to be non-compliant out of which 10 were males and 16 were female patients. 15 patients did not understand the instructions properly, 8 patients did not get enough time to practice, family members of 10 patients could not help the patient in performing and understanding IS, family members of 8 patients did not have adequate time for the patient.

Conclusion:

A non-compliance rate of 26% could be because patients and family members did not understand the seriousness of preoperative IS in spite of explaining and giving an information leaflet. The surgeries planned were major ones which require arrangement of finances, abstinence from work and other social issues like not having anybody at home with other family members, location of hospital far from the place they live. Involving respiratory therapist and nursing staff early during pre-anaesthesia check up could help in better understanding of the patient and family regarding benefits of IS.

Efficacy of continuous positive airway pressure and incentive spirometry on respiratory functions during the postoperative period following supratentorial craniotomy: A prospective randomized controlled study

STUDY OBJECTIVE

Volume controlled ventilation with low PEEP is used in neuro-anesthesia to provide constant PaCO₂ levels and prevent raised intracranial pressure. Therefore, neurosurgery patients prone to atelectasis formation, however, we could not find any study that evaluates prevention of postoperative pulmonary complications in neurosurgery.

DESIGN

A prospective, randomized controlled study.

SETTING

Intensive care unit in a university hospital in Istanbul.

PATIENTS

Seventy-nine ASAI-II patients aged between 18 and 70years scheduled for elective supratentorial craniotomy were included in the study.

INTERVENTIONS

Patients randomized into 3 groups after surgery. The Group IS (n=20) was treated with incentive spirometry 5 times in 1min and 5min per hour, the Group CPAP (n=20) with continuous positive airway pressure 10 cmH₂O pressure and 0.4 F_iO₂ via an oronasal mask 5min per hour, and the Group Control (n=20) 4L·min^-1O₂ via mask; all during the first 6h postoperatively. Respiratory functions tests and arterial blood gases analysis were performed before the induction of anesthesia (Baseline), 30min, 6h, 24h postoperatively.

MAIN RESULTS

The IS and CPAP applications have similar effects with respect to FVC values. The postoperative 30min FEV₁ values were statistically significantly reduced compared to the Baseline in all groups (p<0.0001). FEV₁ values were statistically significantly increased at the postoperative 24h compared to the postoperative 30min in the Groups IS and CPAP (p<0.0001). This increase, however, was not observed in the Group Control, and the postoperative 24h FEV₁ values were statistically significantly lower in the Group Control compared to the Group IS (p=0.015).

CONCLUSION

Although this study is underpowered to detect differences in FEV₁ values, the postoperative 24h FEV₁ values were significantly higher in the IS group than the Control group and this difference was not observed between the CPAP and Control groups. It might be evaluate a favorable effect of IS in neurosurgery patients. But larger studies are needed to make a certain conclusion.

Effect of preoperative incentive spirometry on fentanyl-induced cough: a prospective, randomized, controlled study

Background

Fentanyl-induced cough (FIC) has a reported incidence of 13–65% on induction of anesthesia. Incentive spirometry (IS) creates forceful inspiration, while stretching pulmonary receptors. We postulated that spirometry just before the fentanyl (F) bolus would decrease the incidence and severity of FIC.

Methods

This study enrolled 200 patients aged 18–60 years and with American Society of Anesthesiologists status I or II. The patients were allocated to two groups of 100 patients each depending on whether they received preoperative incentive spirometry before fentanyl administration. Patients in the F+IS group performed incentive spirometry 10 times just before an intravenous bolus of 3 µg/kg fentanyl in the operating room. The onset time and number of coughs after fentanyl injection were recorded as primary outcomes. Any significant changes in blood pressure, heart rate, or adverse effects of the drug were recorded as secondary outcomes.

Results

Patients in the F+IS group had a significantly lower incidence of FIC than in the F group (6% vs. 26%) (P < 0.05). The severity of cough in the F+IS group was also significantly lower than that in group F (mild, 5 vs. 17; moderate 1 vs. 7; severe, 0 vs. 2) (P < 0.05). The median onset time was comparable in both groups (9 s [range: 6–12 s] in both groups).

Conclusions

Preoperative incentive spirometry significantly reduces the incidence and severity of FIC when performed just before fentanyl administration.

Do simple beside lung function tests predict morbidity after rib fractures?

BACKGROUND

We evaluated if incentive spirometry volume (ISV) and peak expiratory flow rate (PEFR) could predict acute respiratory failure (ARF) in patients with rib fractures.

METHODS

Normotensive, co-operative patients were enrolled prospectively. ISV and PEFR were measured on admission, at 24 h and at 48 h by taking the best of three readings each time. The primary outcome, ARF, was defined as requiring invasive or noninvasive positive pressure ventilation.

RESULTS

99 patients were enrolled (median age, 77 years). ARF occurred in 9%. Of the lung function tests, only a low median ISV at admission was associated with ARF (500 ml vs 1250 ml, p = 0.04). Three of 69 patients with ISV of ≥1000 ml versus six of 30 with ISV <1000 ml developed ARF (p = 0.01). Other significant factors were: number of rib fractures, tube thoracostomy, any lower-third rib fracture, flail segment.

CONCLUSION

PEFR did not predict ARF. Admission ISV may have value in predicting ARF.

Inspiratory muscle training with threshold or incentive spirometry: Which is the most effective?

Inspiratory muscular training (IMT) increases the respiratory muscle strength, however, there is no data demonstrating its superiority over the incentive spirometry (IS) in doing so. Values of muscle strength after IMT (Threshold IMT(®)) and by the IS (Voldyne(®)) in healthy females was compared. Subjects (n=40) were randomly divided into control group (CG, n=14), IS group (ISG, n=13) and threshold group (TG, n=13). PImax was measured before (pre-IMT), at 15 and 30 days of IMT. There was an increase in PImax of the TG at 15 days (p<0.001) and 30 days of IMT (p<0.001). The same occurred with the ISG, which increased the PImax at 15 days (p<0.001) and 30 days of training (p<0.001). After 30 days of IMT, the TG presented a PImax which was significantly higher than ISG and the CG (p=0.045 and p<0.001, respectively). It can be concluded that IMT by threshold was more effective in increasing muscle strength than the Voldyne.