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Administering Incentive Spirometry |   |
As with IPPB, the successful application of IS involves three phases: planning, implementation, and followup. Since many of the components of this process are similar to those previously described, only the key points and differences in approach are discussed here.
Preliminary Planning
During preliminary planning, the need for IS should be determined, and desired therapeutic outcomes should be set. In terms of need, the clinical situations indicating a need for incentive spirometry include:
- Surgical procedure involving upper abdomen or thorax
- Conditions predisposing to development of atelectasis including immobility, poor pain control, and abdominal binders
- Presence of neuromuscular disease involving respiratory muscles
Once the need for IS has been established, planning for IS should focus on selecting explicit therapeutic outcomes. The potential outcomes that can be considered for patient receiving incentive spirometry include:
Absence of or improvement in signs of atelectasis:
- Decreased respiratory rate
- Remission of fever
- Normal pulse rate
- Resolution of abnormal breath sounds
- Normal chest X-ray
- Improved PaO2 and decreased P(A-a)02
- Increased VC and peak expiratory flows
- Restoration of pre-op FRC or VC
Improved inspiratory muscle performance:
- Attainment of preoperative flow and volume levels
- Increased forced vital capacity (FVC)
The outcomes applicable to a given patient clearly depend on the diagnostic information that supports the need for IS. In that sense, the patient's baseline assessment is critical. Ideally, patients scheduled for upper abdominal or thoracic surgery should be screened prior to undergoing this procedure.
Assessment of the patients at this point will help identify those at high risk for postoperative complications, and allow determination of their baseline lung volumes and capacities. This approach also provides an opportunity to orient high-risk patients to the procedure before undergoing surgery, thereby increasing the likelihood of success when incentive spirometry is provided after surgery.
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Implementation of Incentive Spirometry The success of incentive spirometry depends heavily on effective patient instruction. When teaching a patient to use an incentive spirometer, the RCP should set an initial goal that is attainable, but requires some moderate effort. Setting too low an initial goal results in little incentive and an ineffective maneuver, at least initially. The patient should be instructed to inspire slowly and deeply in order to maximize the distribution of ventilation. |
During initial attempts, patients frequently tend to inspire very rapidly, using the accessory muscles of ventilation to aid the work of the diaphragm. Correct instructional technique will emphasize diaphragmatic breathing at a slow to moderately inspiratory flows. Demonstration is probably the most effective way to ensure patient understanding and cooperation. By using oneself as an example, both the operation of the device and the proper breathing technique can be easily explained, and much trial and error avoided.
When maximal inspiration is reached, the patient should be instructed to sustain that breath for 5 to 10 seconds. Many patients have difficulty with this aspect of the maneuver. The breath-hold should be followed by a normal exhalation, and the patient should be given the opportunity to rest as long as needed prior to the next SMI maneuver. Some patients in the early postoperative stage may need to rest for as much as 30 seconds to a minute between maneuvers. This rest period helps avoid a common tendency among some patients to repeat the maneuver at rapid rates, thereby causing respiratory alkalosis. The goal is not rapid, partial lung inflation but intermittent, maximal inspiration.
The number of sustained maximal inspirations needed to reverse or prevent atelectasis varies according to the patient's clinical status. However, because normal individuals average about 6 sighs per hour, an IS regimen should probably aim to ensure a minimum of 5 to 10 SMI maneuvers each hour.
Followup
Assessing the patient's performance is vital to ensuring goals achievement. To accomplish this, the RCP return to monitor treatment sessions until correct technique and appropriate effort are achieved. Suggested monitoring activities for IS include:
- Observation of patient performance and use:
Frequency of sessions
Number of breaths/session
Volume/flow goals achieved
Breath-hold maintained
Effort/motivation
- Periodic observation of patient compliance, with additional instruction
as needed
- Device within reach of patient and patient encouraged to perform independently
- New and increasing inspiratory volumes established each day
- Vital signs
Once the patient has mastered the technique, IS may be performed with minimal supervision. Even when self-administered, records of progress, as related to the patient's clinical status, must be maintained throughout the course of treatment. The result of this assessment can guide the physician and RCP in revising the respiratory care plan or terminating treatment once its goals are achieved.