Pulmonary Complications and Incentive Spirometry

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Introduction

After abdominal surgery, many patients tend to develop difficulty in breathing or basically the functioning of the whole pulmonary system. These problems can escalate and cause serious pulmonary complications. Its been found that these complications are a cause of the high rates of morbidity and mortality among patients who have undergone abdominal surgery. Chest therapy is a process that is intended to reduce the probability of developing these complications and accelerate the process of recovery. There are some interventions like physical exercises that are very good for maximizing inspiration and they have been rated to be the most beneficial for these recovering patients. Another method of hastening recovery and improving inspiration effort is the use of an incentive spirometer (IS). This is a simple medical device that is used by recovering patients from surgery to maximize their inspiration to effective levels. A study by Westwood et al revealed that adding the use of this handheld incentive Spirometry to the recovery program of intensive-post operative physiotherapy was effective in reducing chances of developing complications (17% to 6%, p=0.01) and also reduced the time stayed on the surgical dependency unit from 4 days to 3 days (p=0.03). Other factors like age, patients smoking history, sex, use of analgesics and the emergency surgery need were all factored in the research.

Literature Review

Incentive Spirometry Reduces Complication

About 25-50% of all patients who under abdominal surgery suffer pulmonary complications and this at times end up in mortality since its morbidity are very high among these patients. These complications also cause great discomfort among the patients, increased utilization of medical resources and lengthy stay at health facilities and hence the overall high costs of medication (Westwood, 2007, p. 339). In order to try and solve these problems, chest physiotherapy has been the generally accepted means of intervention and its widely used by many facilities in their surgical units to decrease the post-operative pulmonary complications (PPC). However, there is limited evidence for the efficiency of the method and researches that have been conducted to compare various physiotherapy modalities are also few (Westwood, 2007, p. 339). Patients with abdominal or chest incisions from surgery state that they suffered more pain on their wound and sometimes they would experience dysfunctional diaphragm. This at times may compromise the normal respiration.

Atelectasis is a medical parlance that is used to describe the pathology of alveolar collapse (Westwood, 2007, p. 339). The process begins during general anesthesia and this can continue even after surgery in the post-operative care especially among those patients who do not have the capability of achieving the effective tidal volume. Opiate analgesia and dysfunctional diaphragm are the main common means through which cause patients to experience reduced inspiration (Westwood, 2007, p. 339). During such experience, there is reduced tidal volume which decreases distending forces of the air sacs and this allows alveolar collapse. The lungs then suffer restrictive lung defects and this result into decreased lung movement, poor clearance of mucocilliary, surfactant lessening, and the body becomes predisposed to more infection (Westwood, 2007, p. 339).

The aim of respiratory physiotherapy is to enhance inspiration so that alveoli can expand during inhalation and stop further atelectasis. The incentive spirometer is specifically designed to achieve this and then sustain maximum inspiration (Westwood, 2007, p. 339). Its simple to use and patients can get the feedback of the flow and volume of air. The outcomes lead to more effective inspiration, managed flow and more enthusiasm to exercise (Westwood, 2007, p. 339). The instrument has no known side-effects and its cheap and there is no supervision required for the patients to use its once they undergo the basic training.

Comparing Postoperative Respiratory Care Methods

The intermittent Positive pressure breathing (IPPB) is a highly disapproved method of managing postoperative complications basically because there are no enough valid studies that can attest its clinical efficiency regardless of its continued use. Additionally, morbidity and sometimes eventual death could be associated with this type of therapy (Dohi & Gold, 1978, p. 592). Several alternatives of respiratory care are in place and they include chest physiotherapy, incentive Spirometry, carbon dioxide hyperventilation, and use of deep-breathing exercise and blow bottles used for resistance breathing. Triflo Deep Breathing Exercise is one of the cheaper disposable spirometers that measures the flow of air through a partitioned chamber with three balls arranged in series (Dohi & Gold, 1978, p. 592). These balls rise successively when pressure is negative with high inspiration flow. Every ball at the top is equivalent to one liter per second of voluntary inspiration.

Dohi and Gold compared IPPB versus incentive spirometer in a research. Incentive Spirometry through the Trillo device is equivalent to IPPB spirometrically. The clinical evidence showed that the patients who were managed with incentive spirometer were improving much faster and effectively (Stock, 1985, p. 152). Out of the 34 patients that were treated with the instrument, ten of them developed pulmonary complications whereas 17 out of the 30 who were treated by the IPPB experienced these post operative complications (Dohi & Gold, 1978, p. 593). The patients selected for the study were elderly, had history of smoking and all had been operated on their abdomen with a considerable number of them having it done on their upper abdomen. This means that the patients were so much prone to the pulmonary complications (Dohi & Gold, 1978, p. 594). The results obtained indicated that the incentive spirometer was more effective that the IPPB though with a very small significance of P<0.051. Dohi and Gold believe that this is not enough conclusions but it represents a trend that is likely to be observed. The spirometer is justified for use in the episodic events and cheaper than IPPB (Dohi & Gold, 1978, p. 594).

Patients are encouraged by doctors, nurses and therapists of the respiratory system to use the incentive spirometer and this greatly inspires patients with great insights into it and the hourly change. Even though some of the patients indicated that they felt better after the use of IPPB, the longer interval of up to six hours from four between the administration could not be equal to the hour-to-hour self administration that the Spirometry offers in a similar subjective improvement (Dohi & Gold, 1978, p. 594). On the whole, there is no significant difference in spirometrical results between the two modes of therapy. Discomfort, sleepiness and pain are elevated at the beginning of the therapy but as the spirometric outcomes improve, these sign fade off, the wound heals and then ambulation takes place (Dohi & Gold, 1978, p. 595). Perhaps the diaphragm can be strengthened by breathing exercises like deep breathing five times every hour. This characteristic lacks in the use of IPPB. Since its invention in 1970, there has been an increase in the number of studies supporting its deep breathing exercise hence making it more popular as IPPB use declines (Dohi & Gold, 1978, p. 595).

Based on the study by Jung et al conducted to compare the spirometer against IPPB and resistance breathing, the incentive Spirometry is not better than the other methods in managing postoperative problems (Jung et al, 1980, p. 34). Resistance breathing and the spirometer are only somewhat better becaseu of users preferences. However, it was difficult for them to determine whether either of the methods significantly, reduced the probability of developing atelectasis (Jung et al, 1980, p. 34). Conclusions reached by Jung et al were that despite there being no difference among the three models, any of them can be used to manage patient in their postoperative period so that they do not develop complications after abdominal surgery (Jung et al, 1980, p. 34). Still, incentive spirometer is hailed as a superior method of managing such patients.

Therapy is better than No Intervention

A meta analysis by Thomas and McIntosh helped them to draw conclusions that deep breathing exercises were more efficient in reducing the probability of developing complication then not physical intervention at all (Thomas & McIntosh, 1994, p. 14). The use of incentive Spirometry to alleviate possibility of developing pulmonary complication after abdominal surgery was also found to be more efficient and beneficial than no therapy though there was not considerable heterogeneity of the results. Its still very difficult to draw any conclusions that regard the efficiency of IPPB against any control as there was not enough information for such calculations (Thomas & McIntosh, 1994, p. 14). There are also no statistically significant differences among the various methods of managing post operative period to alleviate chances of developing complications. Researchers have attributed lack of significant difference to poor methodologies of study or lack of clinical relevant adherence, poor compliance on the part of the patients, or suboptimal doses for treatment (Thomas & McIntosh, 1994, p. 14). Thomas and McIntosh suggest that incentive spirometer and deep breathing exercises should be the main methods used for preventing pneumonia and atelectasis following abdominal surgery.

Methodology

Hall et al evaluated adults who had undergone a laparoctomy for their study of incentive Spirometry. All the patients had undergone a surgery that included manipulating internal viscera and hence those who had undergone groin hernia surgery were excluded from the study (Hall et al, 1996, p. 149). The Royal Perth Hospital, in conjunction with the University of Western Australia ethics committee was behind the approval of the research. Computers were used to generate the numbers to admit patients. The patients were randomized. To determine the high risk patients, the American society of anesthesia method was used for classifying this. The researchers recorded the putative factors just to help determine whether the patients belonged to similar at baseline (Hall et al, 1996, p. 149). The diagnosis of chorionic bronchitis was guided by the UK medical research council. In order for the respondents to be considered current smoker, they were required to have been actively smoked for a period of 8 weeks prior to the study. Patients were each given incentive spirometer with a one way valve to use during the period of study. The patients were advised to use the instrument hourly and at least ten times a day (Hall et al, 1996, p. 149). They would hold their breath as long as possible but slowly to strengthen the breathing mechanism. There was also a mixed therapy that targeted patients who needed physiotherapy to attain maximum effort at least one time and for the first 3 days following surgery and thereafter took on a rate discussed with physiotherapist in charge (Hall et al, 1996, p. 149). The research nurse assessed each of the patients independently considering their compliance with chest therapy.

Respiratory complication was defined as the appearance of features that consistent with collapsing of the alveolar or unexplained higher temperatures or illness that is as a result of sputum microbiology. Respiratory emboli and edema were excluded from being pulmonary complications in this study (Hall et al, 1996, p. 149). Chest radiography was performed to all patients. Radiography was used to check atelectasis and a radiologist made the judgment. Blood gas assessment was carried out at the discretion of the nurse.

The general sample size of 430 patients was considered appropriate determine an absolute 10% difference in the occurrence of post operative complications with a 5% type 1 error (Hall et al, 1996, p. 149). Statsoft and statistical systems were used for analysis.

Discussion

There are several studies that have indicated that an incentive spirometer is the preferred method of managing the postoperative period to prevent development of complications in the respiratory system (Overend et al, 2001, p. 974). In a systematic review by Overend et al, out of 18 papers analyzed, seven supported use of the IS while the rest did not support it claiming that it had efficiency similar to the other methods. The Incentive Spirometry has gained increased use as the best or most preferred model of managing postoperative complications. This is basically difficult to describe why (Overend et al, 2001, p. 974). Hence for proper study, the idea of monitoring compliance merit special address as its unlikely to accurately evaluate the impact of incentive spirometer exclusive of critical information concerning the degree of compliance with the intervention procedure (Stock, 1985, p. 152).

One of the main advantages of the IS process is that patients can take responsibility for their own treatment and therefore reduce the need for nurse therapist to be in contact with the patients (Overend et al, 2001, p. 974).

Ultimately, the most efficient way of prophylactic respiratory therapy has to be the one that closely deal with atelectasis (Hall et al, 1991, p. 955). The earliest therapy model of therapy focused on expiratory maneuvers and tries to dislodge mucus from the bronchioles. Nonetheless such therapy has been found to be efficient only for patient with more 30ml sputum a day (Hall et al, 1991, p. 955). Basically this is because sputum is not a main feature of post operative complication. Moreover, aggressive physiotherapy targeting removal of excessive mucus could cause bronchospasm or transient hypoxemia.

Maximum inspiration attempt can re-inflate the collapsing air sacs and prevent atelectasis or even reverse it. This presumption is based on the fact that the underlying reason for atelectasis is reduced ventilation in lungs due to breathing monotony experienced at perioperative period (Hall et al, 1991, p. 955). Reduced ventilation is basically due to anesthesia, narcotics impact, and pain of the incision wound, weight problems, debility and pre-existing pulmonary disease. Recently, its been purported that the chest cavity and diaphragm dysfunction could be critical in the genesis of postoperative complications (Hall et al, 1991, p. 955). The IS cannot efficiently re-inflate alveoli when the chest wall is almost shattered and a floppy diaphragm.

Conclusion

Patients who go through abdominal surgery suffer abdominal pain and reduced functionality of the pulmonary system during the postoperative period. However there is usually no big change to the reduced lung volumes to clinically relevant levels. Patients who are treated usually recover from the restrictive complications like in the case of using IS. Even though the incentive spirometer has shown no significant benefit over other intervention, it has gained more popularity and is used more than any other intervention technique. The reason could be because of convenience and self administration ability.

Reference List

Dohi, S & Gold, I. (1978). Comparison of Two Methods of Postoperative Respiratory Care. Chest, 73: 592-595

Hall, J.C., et al (1991). Incentive Spirometry versus Routine Chest Physiotherapy for Prevention of Pulmonary Complications after Abdominal Surgery. Lancet, 337(8747): 952-957

Hall, J.C., et al. (1996). Prevention Of respiratory Complications after Abdominal Surgery: A Randomized Clinical Trial. BMJ, 312: 148-152

Jung, R. et al (1980). Comparison of Three Methods of Respiratory Care Following Upper Abdominal Surgery. Chest, 78: 31-35

Overend, T.J, et al (2001). The Effect of Incentive Spirometry on Postoperative Pulmonary Complications: A Systematic Review. Chest, 120: 971-978

Stock, M.C. (1985). Prevention of Postoperative Pulmonary Complications with CPAP, Incentive Spirometry, and Conservative Therapy. Chest, 87: 151-157

Thomas, J & McIntosh, J. (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): 5-16

Westwood, K. (2007). Incentive Spirometry Decreases Respiratory Complications Following Major Abdominal Surgery. Surgeon, 5(6): 339-342

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