Incentive Spirometry in Non-critically Ill Hospitalized Patients With Acute Respiratory Failure
Incentive Spirometry in Non-critically Ill Hospitalized Patients With Acute Respiratory Failure
To evaluate the use of Incentive Spirometry in Non-critically Ill Hospitalized Patients With
 Shortness of Breath.
In recent years the focus in medicine has shifted towards efficient utilization of resources
 and improving patient outcomes. Incentive spirometry (IS) is a tool that mimics the natural
 process of yawning or sighing by allowing the user to take deep breaths in a controlled
 setting. This is a lung inflating maneuver that has been suggested to decrease the rate of
 pulmonary complications. The focus of utilization of IS and current studies has been
 predominantly on the post-operative surgical patient population. The mechanism of pulmonary
 complications in surgical patients is mixed in etiology possibly related to anesthesia,
 analgesics, pain and immobility leading to shallow breathing and subsequent atelectasis with
 concurrent hypoxia and risk of infection. The use of lung expanding maneuvers such as that
 provided by IS are thought to counteract shallow breathing thereby improving pulmonary
 outcomes. However, contrary to physiological theory, multiple studies and meta-analysis have
 failed to demonstrate its efficacy. The results of these studies are in direct conflict with
 what is expected scientifically.

 The authors of this paper set out to find the reason for discordant data in existing
 literature, and found that there have been multiple methodological limitations associated
 with existing studies; hence, interpretation and recommendations based on current data should
 be done with caution. The common denominator in repeated criticisms of existing studies is
 lack of reporting on patient compliance with IS after it is prescribed. This is a major
 confounder, in clinical experience IS is often observed sitting dormant at patients' bedside.
 These observations are in synchrony with criticisms reported in literature and raise serious
 questions about validity of existing data that should be acknowledged. Despite lack of
 convincing evidence, IS is routinely prescribed by physicians in hospital medicine. IS is a
 low cost tool, nevertheless, the increasing frequency of its use is accumulating to a larger
 proportion of health care costs. This calls for further evaluation with a study of higher
 methodological quality to address the limitations of prior studies.

 The scope of this study is different than that of existing studies in that it will evaluate
 the utility of IS in general medical patients. The sub-set of patients that are the focus of
 this study are those admitted with the chief complaint of "shortness of breath." The disease
 process in the former group leading to shortness of breath includes fluid over-load such as
 that in congestive heart failure, or an underlying lung process such as pneumonia, COPD,
 and/or pulmonary embolism. There is a parallel between mechanism of hypoxia in these patients
 and surgical patients in that these patients too often have pain and take high doses of
 analgesics, have shallow monotonous breathing and are immobile for long periods of time. From
 a physiological standpoint sustained maximal inhalation maneuvers may reverse and prevent
 progression of atelectasis by maintaining airway patency in all patients with shallow
 breathing of varying etiology not just the surgical sub-set.

 In a tertiary center community teaching hospital the effectiveness of IS in general medical
 wards will be evaluated using a single center randomized clinical trial. The goal is to offer
 a study that overcomes the limitations of prior studies. Lack of strong evidence based data
 has led to inconsistencies in practice of physicians leading to higher health care costs. The
 authors hope to design a study of high methodological quality to assess the effectiveness of
 IS in medical patients; thereby closing the knowledge gap in evidence based practices that
 may aid physicians in their decision to utilize IS.
Inclusion:

 -  Patients presenting to the ED with chief complaint of "shortness of breath," admitted
 to the hospitalist service

 -  Age >65 yrs of age

 Exclusion:

 -  Patients who can not follow instructions/use IS device

 -  Cognitive impairment (Dementia/delirium/Developmental delay)

 -  Heavy sedation

 -  Inability to take part in deep breathing due to pain or diaphragmatic dysfunction

 -  Suicide or psych watch

 -  Patients under isolation

 -  ICU admission or care within the last 48 hours

 -  Recent hospitalization 30 days.

 -  Intubation within the last 60 days

 -  Routine care group patients that have IS prescribed to them by the admitting MD

 -  Chronic/Home oxygen dependence