Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery: Cochrane systematic review
Assessed as up to date: 2013/08/12
This is an update of a Cochrane Review first published in The Cochrane Library 2008, Issue 3.
Upper abdominal surgical procedures are associated with a high risk of postoperative pulmonary complications. The risk and severity of postoperative pulmonary complications can be reduced by the judicious use of therapeutic manoeuvres that increase lung volume. Our objective was to assess the effect of incentive spirometry compared to no therapy or physiotherapy, including coughing and deep breathing, on all-cause postoperative pulmonary complications and mortality in adult patients admitted to hospital for upper abdominal surgery.Objectives
Our primary objective was to assess the effect of incentive spirometry (IS), compared to no such therapy or other therapy, on postoperative pulmonary complications and mortality in adults undergoing upper abdominal surgery.
Our secondary objectives were to evaluate the effects of IS, compared to no therapy or other therapy, on other postoperative complications, adverse events, and spirometric parameters.Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE, EMBASE, and LILACS (from inception to August 2013). There were no language restrictions. The date of the most recent search was 12 August 2013. The original search was performed in June 2006.Selection criteria
We included randomized controlled trials (RCTs) of IS in adult patients admitted for any type of upper abdominal surgery, including patients undergoing laparoscopic procedures.Data collection and analysis
Two authors independently assessed trial quality and extracted data.Main results
We included 12 studies with a total of 1834 participants in this updated review. The methodological quality of the included studies was difficult to assess as it was poorly reported, so the predominant classification of bias was 'unclear'; the studies did not report on compliance with the prescribed therapy. We were able to include data from only 1160 patients in the meta-analysis. Four trials (152 patients) compared the effects of IS with no respiratory treatment. We found no statistically significant difference between the participants receiving IS and those who had no respiratory treatment for clinical complications (relative risk (RR) 0.59, 95% confidence interval (CI) 0.30 to 1.18). Two trials (194 patients) IS compared incentive spirometry with deep breathing exercises (DBE). We found no statistically significant differences between the participants receiving IS and those receiving DBE in the meta-analysis for respiratory failure (RR 0.67, 95% CI 0.04 to 10.50). Two trials (946 patients) compared IS with other chest physiotherapy. We found no statistically significant differences between the participants receiving IS compared to those receiving physiotherapy in the risk of developing a pulmonary condition or the type of complication. There was no evidence that IS is effective in the prevention of pulmonary complications.Authors' conclusions
There is low quality evidence regarding the lack of effectiveness of incentive spirometry for prevention of postoperative pulmonary complications in patients after upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field. There is a case for large RCTs with high methodological rigour in order to define any benefit from the use of incentive spirometry regarding mortality.
do Nascimento Junior Paulo, Módolo Norma SP, Andrade Sílvia, Guimarães Michele MF, Braz Leandro G, El Dib Regina
Incentive spirometry for prevention of postoperative pulmonary complications after upper abdominal surgery
Previous studies have suggested that between 17% and 88% of people having surgery on the upper abdomen will suffer complications that affect their lungs after the operation (postoperative pulmonary complications). The lung volume tends to fall after such surgeries. These complications can be made less likely and less severe with the careful use of treatments designed to encourage breathing in (inspiration) and thus increasing the volume of the lungs, as these volumes tend to fall after such surgeries. Incentive spirometers are mechanical devices developed to help people take long, deep, and slow breaths to increase lung inflation.
We reviewed the evidence about the effect of incentive spirometry (IS), compared to no intervention or other therapy, to prevent postoperative pulmonary complications (for example, pneumonia, fever, death) in people following upper abdominal surgery.
We included adults (aged 18 years and above) admitted for any type of upper abdominal surgery. The evidence is current to August 2013. We found 12 studies with a total of 1834 participants. The maximum period of time that a patient was followed by the doctor was seven days postoperatively. The quality of the included studies was uncertain because of poor reporting in the published articles.
The following results were examined in this review: clinical complications, respiratory failure (that is, inadequate gas exchange by the respiratory system), and pulmonary complications. The results from participants receiving IS were the same as for those receiving either no treatment, deep breathing exercises (DBE) or physiotherapy in the meta-analyses for clinical complications, respiratory failure, and pulmonary complications.
Quality of evidence
Because of poorly conducted studies (results not similar across studies; some issues with study design and; not enough data collected and organized) we ranked the overall quality of the evidence reported in this review as low.
Conclusion and future research
There is low quality evidence showing a lack of effectiveness of incentive spirometry for prevention of postoperative pulmonary complications in patients after upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field.
Implications for practice
There is low quality evidence regarding the lack of effectiveness of incentive spirometry for prevention of postoperative pulmonary complications in patients after upper abdominal surgery.
Implications for research
Future randomized controlled clinical trials should have standardized outcome measures such as pulmonary complications, total mortality from respiratory causes, and all-cause mortality. Dropouts and losses to follow up need to be clearly reported.
Future studies should also address the issue of compliance with treatment, for example, the study must be designed to address efficacy or efficiency. Besides that, future studies must be adequately powered and assess patients at a common time point, or points, following surgery. Treatment modalities described as standard care, or similar, must be carefully defined and must be identically applied in both the control and experimental groups.Get full text at The Cochrane Library
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