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How to read a spirometry report

how to read a spirometry report


The levels of evidence (A-D ) and the strength of the recommendations (1-2 ) are defined at the end of the "Major Recommendations" field. The words "recommended" and "suggested" are used to reflect the strength of the recommendation, as level 1 and level 2, respectively.

Incentive spirometry, also referred to as sustained maximal inspiration, is accomplished by using a device that provides feedback when the patient inhales at a predetermined flow or volume and sustains the inflation for at least 5 seconds. The patient is instructed to hold the spirometer in an upright position, exhale normally, and then place the lips tightly around the mouthpiece. The next step is a slow inhalation to raise the ball (flow-oriented) or the piston/plate (volume-oriented) in the chamber to the set target. At maximum inhalation, the mouthpiece is removed, followed by a breath-hold and normal exhalation. Instruction of parents, guardians, and other health caregivers in the technique of incentive spirometry may help to facilitate the patient's appropriate use of the technique and assist with encouraging adherence to therapy.

Limitations of Method

The usefulness of prophylactic respiratory therapy, including incentive spirometry, for the prevention of clinically relevant postoperative pulmonary complications is controversial.

  • The effectiveness of incentive spirometry may depend on patient selection, careful instruction, and supervision during respiratory training.
    • Inadequate training and insufficient self-administration of incentive spirometry may result in lack of resolution of postoperative complications (Christensen et al. 1991).
  • Evidence strongly suggests that incentive spirometry alone may be inappropriate to prevent or treat postoperative complications (Schwieger et al. 1986; Hall et al. 1991; Melendez et al. 1992).
  • Respiratory therapy, with or without incentive spirometry, may have similar clinical outcomes.
    • Preoperative and postoperative respiratory therapy that includes deep breathing exercises, directed cough, early mobilization, and optimal analgesia (Ballantyne et al. 1998; Desai, 1999; Winters, 2009), with or without incentive spirometry, appears to be effective in preventing or reversing complications after thoracic surgery (Weiner et al. 1997; Agostini et al. 2008; Agostini & Singh, 2009; Gosselink et al. 2000; Varela et al. 2006), cardiac surgery (Pasquina, Tramer, & Walder, 2003; Dias et al. 2011; Crowe & Bradley, 1997), abdominal surgery (Mang & Kacmarek, 1991; Hall et al. 1996; Thomas & McIntosh, 1994; Pasquina et al. 2006; Guimarâes et al. 2009; Bapoje et al. 2007; Overend et al. 2001), and peripheral surgery in obese adults (Zoremba et al. 2009).
    • Evidence is lacking for benefit of incentive spirometry in reducing pulmonary complications and in decreasing the negative effects on pulmonary function in patients undergoing coronary artery bypass graft surgery (Overend et al. 2001; Westerdahl et al. 2005; Freitas et al. 2007; Romanini et al. 2007; Renault et al. 2009).
    • Incentive spirometry has not been associated with significant improvements of inspiratory capacity prior to laparoscopic bariatric surgery and may not be useful to prevent postoperative decrease in lung function (Cattano et al. 2010; Kundra et al. 2010).
    • There is no significant difference between deep breathing with directed cough and incentive spirometry in the prevention of postoperative pulmonary complications following esophagectomy (Vats, 2009).
    • In patients with neuromuscular disease, incentive spirometry may not be as effective as intrapulmonary percussion ventilation in preventing atelectasis (Reardon et al. 2005).
  • Critical care
  • Acute care in-patient
  • Extended care and skilled nursing facility
  • Home care
  • Preoperative screening of patients at risk for post-operative complications to obtain baseline flow or volume (Agostini et al. 2008; Kips, 1997; Larson et al. 2009).
  • Respiratory therapy that includes daily sessions of incentive spirometry plus deep breathing exercises, directed coughing, early ambulation, and optimal analgesia may lower the incidence of postoperative pulmonary complications.
  • Presence of pulmonary atelectasis or conditions predisposing to the development of pulmonary atelectasis when used with:
    • Upper-abdominal or thoracic surgery (Westwood et al. 2007)
    • Lower-abdominal surgery (Pappachen et al. 2006)
    • Prolonged bed rest
    • Surgery in patients with chronic obstructive pulmonary disease (COPD)
    • Lack of pain control (Bellet et al. 1995)
    • Presence of thoracic or abdominal binders
    • Restrictive lung defect associated with a dysfunctional diaphragm or involving the respiratory musculature
      • Patients with inspiratory capacity 2.5 L (Weindler & Kiefer, 2001)
      • Patients with neuromuscular disease
      • Patients with spinal cord injury (Chureemas & Kovindha, 1992)
  • Incentive spirometry may prevent atelectasis associated with the acute chest syndrome in patients with sickle cell disease (Bellet et al. 1995; Hsu, Batts, & Rau, 2005).
  • In patients undergoing coronary artery bypass graft (Yánez-Brage et al. 2009)
    • Incentive spirometry and positive airway pressure therapy may improve pulmonary function and 6-minute walk distance

      and reduce the incidence of postoperative complications (Haeffener et al. 2008; Ferreira et al. 2010).


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  • Patients who cannot be instructed or supervised to assure appropriate use of the device
  • Patients in whom cooperation is absent or patients unable to understand or demonstrate proper use of the device
    • Very young patients and others with developmental delays
    • Patients who are confused or delirious
    • Patients who are heavily sedated or comatose
  • Incentive spirometry is contraindicated in patients unable to deep breathe effectively due to pain, diaphragmatic dysfunction, or opiate analgesia. (Wilkins, 2005)
  • Patients unable to generate adequate inspiration with a vital capacity <10 mL/kg or an inspiratory capacity <33% of predicted normal (Wilkins, 2005)

Hazards and Complications

  • Ineffective unless performed as instructed
  • Hyperventilation/respiratory alkalosis
  • Hypoxemia secondary to interruption of prescribed oxygen therapy
  • Fatigue
  • Pain

Assessment of Need

  • Surgical procedure involving abdomen or thorax
  • Conditions predisposing to development of atelectasis, including immobility and abdominal binders

Assessment of Outcomes

  • Resolution or improvement in signs of atelectasis
    • Decreased respiratory rate
    • Absence of fever
    • Normal pulse rate
    • Improvement in previously absent or diminished breath sounds
    • Improved radiographic findings
    • Improved arterial oxygen tension (partial pressure of oxygen in arterial blood [PaO2 ], saturation of oxygen in arterial blood [SaO2 ], pulse oximeter oxygen saturation [SpO2 ], reduced fraction of inspired oxygen [FIO2 ] requirement)
  • Equipment
    • Volume-oriented incentive spirometer
      • Volume-oriented incentive spirometers are frequently associated with lower imposed work of breathing and larger inspiratory lung volume than flow-oriented incentive spirometers (Weindler & Kiefer, 2001; Parreira et al. 2005; Mang, Obermayer, & Weindler, 1988; Ho et al. 2000; Yamaguti et al. 2010).
      • Incentive spirometers with a low additional imposed work of breathing might be more suitable for postoperative respiratory training (Weindler & Kiefer, 2001).
    • Flow-oriented incentive spirometer
  • Personnel
    • Clinical personnel should possess:
      • Ability to implement standard/universal precautions
      • Mastery of techniques for proper operation and clinical application of device
      • Ability to instruct patient in proper technique
      • Ability to respond appropriately to adverse effects
      • Ability to identify need for therapy, response to therapy, and need to discontinue ineffective therapy

Direct supervision of every patient use of incentive spirometry is not necessary once the patient has demonstrated mastery of technique. However, intermittent reassessment is essential to optimal performance.

  • Observation of patient performance and utilization
    • Frequency of sessions
    • Number of breaths/session
    • Inspiratory volume, flow, and breath hold goals achieved
    • Effort/motivation
  • Device within reach of patient to encourage performing without supervision

Evidence is lacking for a specific frequency for use of incentive spirometry. Some suggestions have been made in clinical trials.

  • Ten breaths every one (Rafea et al. 2009) to two (Bellet et al. 1995) hours while awake
  • Ten breaths, 5 times a day (Renault et al. 2009)
  • Fifteen breaths every 4 hours (Kundra et al. 2010)

After proper instruction and return demonstration, the patient should be encouraged to perform incentive spirometry independently.

Infection Control

  • Centers for Disease Control guidelines for standard precautions should be followed.
  • All equipment and supplies should be appropriately disposed of or disinfected according to manufacturer recommendations.


The following recommendations are made following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) scoring system (Restrepo, 2010):

  1. Incentive spirometry alone is not recommended for routine use in the preoperative and postoperative setting to prevent postoperative pulmonary complications (1B ).
  2. It is recommended that incentive spirometry be used with deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent postoperative pulmonary complications (1A ).
  3. It is suggested that deep breathing exercises provide the same benefit as incentive spirometry in the preoperative and postoperative setting to prevent post-operative complications (2C ).
  4. Routine use of incentive spirometry to prevent atelectasis in patients after upper-abdominal surgery is not recommended (1B ).
  5. Routine use of incentive spirometry to prevent atelectasis after coronary artery bypass graft surgery is not recommended (1A ).
  6. It is suggested that a volume-oriented device be selected as an incentive spirometry device (2B ).

Strength of the Recommendations and Grade of Quality of the Evidence

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