Postoperative Pulmonary complications (PPC) such as atelectasis, impaired gas exchange, pneumonia and acute respiratory failure (ARF) are not uncommon in patients undergoing major surgery and are a leading cause of increased patient morbidity, mortality and increased length of hospital stay (Yoder, Sharma, Hollingsworth, Talavera, & Rice, 2013). Healthcare professionals are now expected to give patients verifiably effective treatments by implementing current evidence based practice (EBP). In order to do so, interventions to prevent PPCs must be investigated. The aim of this study was to evaluate the effectiveness of adding incentive spirometry (IS) to traditional postoperative chest physiotherapy (CPT) and respiratory care. Eighty patients between 30 and 50 year old who had undergone surgery participated in the study. Patients were divided into two groups: the intervention group where IS was used in addition to the traditional CPT, and the control group which included only traditional CPT. The results obtained in the investigation indicated that there were significant differences between both groups at the end of the study in terms of PPCs and hospital length of stay (LOS). Conclusion: Addition of IS to postoperative care helped in controlling PPCs. Keywords: postoperative pulmonary complication, incentive spirometer, chest physiotherapy, length of Stay
In postsurgical patients, how does using incentive spirometer, compared to not using incentive spirometer, affect incidence of PPCs and hospital LOS?
Because the risk for developing PPCs is not well studied specific numbers of occurrences are difficult to predict. However, it was hypothesized that patients who incorporated IS as part of their postoperative care would have a clinically significant decrease in the occurrence of PPCs and hospital LOS compared to those who did not incorporate IS into their postoperative care. Data Collection
A quasi-experimental control trial was conducted from February 1, 2014 to May 31, 2014. The lead researcher, Adrienne Hinson, collected the data personally. During the four month study, eighty patients ranging in age from 30 to 50 years old who were undergoing surgery where the abdomen or chest was opened were selected randomly from the General Surgery Department at McLeod Regional Medical Center in Florence, SC. On sampling days, patients meeting the criteria were numbered chronologically based on their surgery time. For eighty consecutive business days, one of the patients was chosen randomly using a random numbers table created on Microsoft Excel. Patients who had recently been diagnosed with or treated for acute pulmonary complications, those who could not be instructed or supervised to assure appropriate use of the IS, and patients whose cooperation or comprehension was lacking were excluded from the study.
All appropriate procedures were used to safeguard the rights of study participants. The study was externally reviewed by the hospital’s institutional review board before data collection began. Patients received verbal and written explanations of the study purpose and data collection procedures and after indicating willingness to participate in the study, voluntary informed consent was obtained (See Appendix A). Information included within the informed consent included participant status; participants were told which postoperative activities were routine, and which activities were being evaluated. Participants were informed that the data collected about them would be used for research purposes. The overall goals of the research, to evaluate to addition of IS to postoperative care, was described to patients. Participants were informed about which types of data would be collected, what procedures they would undergo, and how they were selected. The time frame of the commitment was defined as beginning on post-op day one and lasting until their follow up visit after discharge. Information regarding funding was available to participants. All participants were educated on potential risks and benefits of participation. Finally, patients were assured that their privacy would be protected at all times and that they would be allowed to withdraw from the study at any point during their hospital stay (Polit & Beck, 2012).
The patients were deliberately placed into one of two experimental groups. Deliberate placement reduces confounding by ensuring the two groups were comparable when age, sex, smoking history, type of surgery and post-operative analgesia were compared. The control group consisted of 40 patients who underwent routine chest physiotherapy (CPT) postoperatively, as recommended by the Clinical Practice Guidelines set forth by The Agency for Healthcare Research Quality (2011). A physiotherapist supervised and assisted the treatment twice a day in the first two postoperative days and once a day from the third to the tenth days. During any session, the patients performed three to five deep breaths interspersed with periods of quiet breathing followed by two or three coughs or huffs with support from a pillow at least 10 times over a 15 minutes period. Additional techniques such as positioning and chest wall percussion were applied if breathing and coughing exercises alone were not effective in clearing excessive or retained pulmonary secretions. Patients were instructed to perform coughing and deep breathing exercises independently every hour while awake. The treatment group consisted of the remaining 40 patients who also followed the same Clinical Practice Guidelines but also received breathing exercise training with IS (Voldyne Volumetric manufactured by Sherwood Medical Company U.S.A.)
In addition to the routine chest physiotherapy up to the tenth postoperative day. Application of breathing training with incentive spirometry was applied for five minutes, five times a day (El-Marakby et al., 2013). Monitoring began immediately postoperatively and continued until discharge. Hospital LOS was documented for each patient, along with whether or not the patient developed a PPC within 10 days of surgery. The researcher rounded on each hospitalized patient daily to ensure compliance and to update discharges and PPC diagnoses. In order to determine LOS, participant observation was used as a tool to collect data. LOS was calculated by subtracting day of admission from day of discharge. Date of admission was the date of surgery for all participants. Date of discharge was determined by the surgical teams, who were blinded to the study and therefore measures are not likely to be influenced by reactivity (Polit & Beck, 2012). PPCs were defined as any pulmonary abnormality that produced identifiable disease or dysfunction, was clinically significant, and adversely affected the postoperative clinical course (Hayden, Mayer, & Stoller, 1995). Patients were monitored daily for 10 days for the diagnosis of a PPC.
Given this definition, PPCs documented included atelectasis, pneumonia, acute respiratory failure, and exacerbation of COPD. Along with physical assessment and past history, biophysiological measures were used as data collection tools to aid in the diagnosis of PPCs (See Appendix C). Equipment and lab analysis were readily available and tests for biophysiological measures were completed by the appropriate staff at McLeod Regional Medical Center. Ordering tests and the interpretation of results was fulfilled solely by the healthcare providers as deemed necessary. The researchers were not responsible for diagnosing PPCs, but rather the observation and recording of data. Biophysiological measures for diagnosing acute respiratory failure include a low level of oxygen; a pulse oximetry falling below 80% saturation on room air or when arterial blood gas shows PaO2.