AARC Clinical Practice Guideline

IS 1.0 PROCEDURE:

Incentive spirometry, also referred to as sustained maximal inspiration (SMI), is a component of bronchial hygiene therapy.(1-3)

IS 2.0 DESCRIPTION/DEFINITION:

2.1 Incentive spirometry is designed to mimic natural sighing or yawning by encouraging the patient to take long, slow, deep breaths. This is accomplished by using a device that provides patients with visual or other positive feedback when they inhale at a predetermined flowrate or volume and sustain the inflation for a minimum of 3 seconds.

The objectives of this procedure are to increase transpulmonary pressure and inspiratory volumes, improve inspiratory muscle perfor-mance,8 and re-establish or simulate the normal pattern of pulmonary hyperinflation.3 When the procedure is repeated on a regular basis, airway patency may be maintained and lung atelectasis prevented and reversed.

2.2 Incentive spirometry should be contrasted with expiratory maneuvers (such as the use of blow bottles) that do not mimic the sigh and have been associated with the production of reduced lung volumes.

IS 3.0 SETTINGS:

3.1 Critical care

3.2 Acute care inpatient

3.3 Extended care and skilled nursing facility

3.4 Home care(8)

IS 4.0 INDICATIONS:

4.1 Presence of conditions predisposing to the development of pulmonary atelectasis

4.1.1 upper-abdominal surgery

4.1.2 thoracic surgery

4.1.3 surgery in patients with chronic obstructive pulmonary disease (COPD)

4.2 Presence of pulmonary atelectasis

4.3 Presence of a restrictive lung defect associated with quadraplegia and/or dysfunctional diaphragm.

IS 5.0 CONTRAINDICATIONS:

5.1 Patient cannot be instructed or supervised to assure appropriate use of the device.

5.2 Patient cooperation is absent or patient is unable to understand or demonstrate proper use of the device.

5.3 IS is contraindicated in patients unable to deep breathe effectively (eg, with vital capacity [VC] less than about 10 mL/kg or inspiratory capacity [IC] less than about one third of predicted).

5.4 The presence of an open tracheal stoma is not a contraindication but requires adaptation of the spirometer.

IS 6.0 HAZARDS AND COMPLICATIONS:

6.1 Ineffective unless closely supervised or performed as ordered

6.2 Inappropriate as sole treatment for major lung collapse or consolidation

6.3 Hyperventilation

6.4 Barotrauma (emphysematous lungs)

6.5 Discomfort secondary to inadequate pain control

6.6 Hypoxia secondary to interruption of prescribed oxygen therapy if face mask or shield is being used

6.7 Exacerbation of bronchospasm

6.8 Fatigue

IS 7.0 LIMITATIONS OF METHOD:

Evidence suggests that deep breathing alone without mechanical aides can be as beneficial as incentive spirometry in preventing or reversing pulmonary complications, and controversy exists concerning overuse of the procedure.

IS 8.0 ASSESSMENT OF NEED:

8.1 Surgical procedure involving upper abdomen or thorax

8.2 Conditions predisposing to development of atelectasis including immobility, poor pain control, and abdominal binders

8.3 Presence of neuromuscular disease involving respiratory musculature

IS 9.0 ASSESSMENT OF OUTCOME:

9.1 Absence of or improvement in signs of atelectasis

9.1.1 decreased respiratory rate

9.1.2 resolution of fever

9.1.3 normal pulse rate

9.1.4 absent crackles (rales) or presence of or improvement in previously absent or diminished breath sounds

9.1.5 normal chest x-ray

9.1.6 improved arterial oxygen tension (PaO2) and decreased alveolar-arterial oxygen tension gradient, or P(A-a)O2

9.1.7 increased VC and peak expiratory flows

9.1.8 return of functional residual capacity (FRC) or VC to preoperative values4,in absence of lung resection

9.2 Improved inspiratory muscle perfor-mance

9.2.1 attainment of preoperative flow and volume levels1(1)

9.2.2 increased forced vital capacity (FVC)

IS 10.0 RESOURCES:

10.1Equipment

10.1.1 incentive spirometer
 

10.1.2 conclusive evidence to support the use of one type or brand of device over others is lacking

10.2 Personnel

10.2.1 Level I personnel should possess

10.2.1.1 mastery of techniques for proper operation and clinical application of device(6) and understanding of the importance of effective postopera-tive pain relief and the absence of other impediments to patient cooperation (such as residual anesthetic or sensory impairment

10.2.1.2 ability to instruct patient in proper technique and an under-standing of the importance of preoperative instruction and supervised practice

10.2.1.3 ability to respond appropriately to adverse effects

10.2.1.4 knowledge of and ability to implement Universal Precautions

10.2.2 Level II personnel, in addition to possessing knowledge and abilities described in 10.2.1.1-10.2.1.4, should have demonstrated ability to assess patient need for and response to therapy and recommend modifications and discontinu-ance as appropriate.

IS 11.0 MONITORING:

Direct supervision of every patient performance is not necessary once the patient has demonstrated mastery of technique; however, preoperative instruction, volume goals, and feedback are essential to optimal performance.

11.1 Observation of patient performance and utilization

11.1.1 frequency of sessions

11.1.2 number of breaths/session

11.1.3 inspiratory volume or flow goals achieved and 3- to 5-second breath-hold maintained

11.1.4 effort/motivation

11.2 Periodic observation of patient compliance with technique, with additional in-struction as necessary

11.3 Device within reach of patient and patient encouraged to perform independently

11.4 New and increasing inspiratory volumes established each day
 

11.5 Vital signs

IS 12.0 FREQUENCY:

A number of authors suggest using the device 5-10 breaths per session, at a minimum, every hour while awake (ie, 100 times a day). Caregiver does not need to be present with each performance, and patient should be encouraged to perform independently.

IS 13.0 INFECTION CONTROL:

13.1 Universal Precautions

13.2 Proper labeling and appropriate storage of devices between uses and appropriate cleaning of devices between patients

USING BEDSIDE incentive spirometry, your patient learns to take slow, deep breaths to sustain maximal inspiration. The technique is commonly used to prevent or treat atelectasis after upper abdominal or thoracic surgery. Teach him beforehand, when he's more receptive to learning.

DO

* Tell your patient that the reason for incentive spirometry is to help him fully inflate his lungs. Show him the indicator inside the device and explain that the deeper he breathes, the higher it rises.

* Assess his pain level and administer analgesics if necessary.

* For best results, position him as erectly as he can comfortably sit.

* Teach him to exhale completely with his mouth off the spirometer mouthpiece. Then he should seal his lips tightly around the mouthpiece, breathe in as slowly and deeply as possible through his mouth, and note the highest level the indicator reaches. When he can't inhale anymore, he should hold his breath for at least 3 seconds then exhale normally. Encourage him to try to reach his prescribed goal.

* Every hour he's awake, he should do the exercise 5 to 10 consecutive times and follow each session with a deep cough.

* Begin therapy as soon as your patient returns to the unit after surgery because atelectasis can start within an hour. Help him splint his incision to cough.

* Auscultate his breath sounds before and after he uses the spirometer. After he uses it, clean the mouthpiece with water and shake it dry.

* Every 2 hours, document how effectively he performs the procedure without prompting and the number of breaths he takes.

DON'T

* Don't let your patient use incentive spirometry if he can't understand or demonstrate proper use of the device.

* Don't place the spirometer out of his reach.

* Don't let him use a disposable mouthpiece for more than 24 hours.