Incentive Spirometry (IS): Indications, Technique & Patient Education

Incentive Spirometry (IS) is a staple of post-operative respiratory care. It is a lung expansion therapy designed to mimic a natural deep sigh or yawn. By providing visual feedback ("incentive"), it encourages patients to take slow, deep breaths to prevent atelectasis and pneumonia. This guide covers the correct technique, the difference between flow and volume devices, and when not to use it.

1. Purpose: Why do we use it?

The primary goal is to treat or prevent Lung Atelectasis (collapse of alveoli).
Mechanism: It utilizes a Sustained Maximal Inspiration (SMI). A slow, deep breath increases the transpulmonary pressure gradient, popping open collapsed alveoli and improving collateral ventilation.

It is NOT for Expiration!
A common patient error is blowing into the device. Incentive Spirometry is strictly an Inspiratory (breathing IN) exercise.

2. Indications & Contraindications

Indications (Use it for...)	Contraindications (Avoid if...)
• Post-operative patients (abdominal/thoracic surgery). • Bedridden/Immobile patients. • Diagnosis of Atelectasis. • Restrictive lung defects (e.g., quadriplegia).	• Patient cannot understand instructions (Dementia/Delirium). • Patient cannot generate adequate volume (VC < 10-15 ml/kg). • Recent untreated Pneumothorax. • Severe hyperventilation.

3. Types of Spirometers

There are two main designs found in hospitals.

• Volume-Oriented (Volumetric): Measures the actual volume of air inhaled (e.g., 2500ml). The patient inhales until a piston rises to a target mark. (Generally preferred for accuracy).
• Flow-Oriented: Measures the speed of air (flow rate). The patient inhales to keep a ball floating. Volume is estimated by flow x time.

4. How to Use: Step-by-Step Instructions

Correct technique is crucial. Fast, shallow breaths do nothing for atelectasis.

1. Position: Sit upright (High Fowler’s) or at the edge of the bed to allow diaphragm descent.
2. Exhale: Breathe out fully (away from the device).
3. Seal: Put the mouthpiece in the mouth and seal lips tightly.
4. Inhale: Breathe in SLOWLY and DEEPLY through the mouth.
   • Flow Device: Keep the "Good/Best" indicator in the target zone (don't snap the ball to the top).
   • Volume Device: Raise the piston as high as possible.
5. Hold: At the peak of inspiration, HOLD breath for 3-5 seconds. (This is critical for alveolar expansion).
6. Exhale: Remove mouthpiece and breathe out normally.
7. Rest: Take a few normal breaths before the next repetition to prevent dizziness.

5. Frequency & Dosage

How often should it be done? The general rule of thumb is:

• 10 repetitions every waking hour.
• It is better to do small clusters frequently throughout the day than one giant session once a day.
• Encourage use during commercial breaks on TV as a reminder.

6. Common Errors & Solutions

Error	Consequence	Correction
Inhaling too fast	Turbulent airflow; doesn't reach deep alveoli.	"Slow down. Keep the flow ball in the 'Better' zone, not the top."
Blowing INTO the device	Zero therapeutic benefit.	"Suck like a straw, don't blow like a trumpet."
Not holding breath	Alveoli snap shut immediately.	"Hold at the top... 1, 2, 3... now let go."
Hyperventilation	Dizziness, tingling fingers.	"Take breaks. Normal breaths between each rep."

7. Safety: Splinting

⚠️ Post-Op Pain Management
For patients with abdominal or chest incisions, taking a deep breath hurts. Teach them to SPLINT the incision by hugging a pillow firmly against the wound while using the spirometer. This reduces pain and improves effort.

8. Revision Notes for Students

Type of Therapy: Hyperinflation Therapy / Lung Expansion.
Key Maneuver: Sustained Maximal Inspiration (SMI).
Primary Indication: Prevention/Treatment of Atelectasis post-surgery.
Contraindication: Unconscious/Uncooperative patient, untreated pneumothorax.
Physiology: Increases Transpulmonary pressure gradient.
Alternative: If patient is too weak for IS, consider IPPB (Intermittent Positive Pressure Breathing) or CPAP.

9. FAQs

Q1. Does IS clear mucus directly?

Not directly. It expands the lungs. However, the deep breath and subsequent cough after using IS helps clear secretions.

Q2. Can COPD patients use IS?

It is not routinely recommended for stable COPD because lung hyperinflation is already a problem. However, if a COPD patient undergoes surgery, they are at high risk for atelectasis, so IS is used post-operatively for them.

Q3. What if the patient can't reach the target volume?

Move the goal marker down to where they can reach. Success breeds motivation. Gradually increase the target as they improve.

10. 10 Practice MCQs

Q1. The primary goal of Incentive Spirometry is to:

Answer: B) It promotes deep inflation to pop open collapsed alveoli.

Q2. The breathing maneuver used in IS is called:

Answer: C) A slow, deep inhalation followed by a hold.

Q3. How often should a post-op patient use the spirometer?

Answer: B) Frequent, small sessions are best to maintain lung volume.

Q4. A patient complains of dizziness while using the IS. You should:

Answer: C) Dizziness is likely due to hyperventilation (respiratory alkalosis). Resting resolves it.

Q5. Which of the following is a Contraindication for IS?

Answer: B) The therapy requires patient effort and understanding.

Q6. Ideally, the breath hold at the top of inspiration should last:

Answer: B) This pause allows time for the pressure to equalize and expand the alveoli.

Q7. "Splinting" refers to:

Answer: B) Essential for compliance in abdominal/thoracic surgery patients.

Q8. If a patient exhales into the device, the ball/piston will:

Answer: B) IS devices usually have a one-way valve or design that only registers inhalation.

Q9. In a flow-oriented device, the patient should keep the ball:

Answer: C) Keeping it in the middle zone ensures a SLOW, laminar flow, which is better for distribution.

Q10. The best position for performing IS is:

Answer: A) Upright positioning maximizes diaphragmatic excursion and lung volume.

References

• AARC Clinical Practice Guideline. (2011). Incentive Spirometry. Respiratory Care.
• Restrepo, R. D., et al. (2011). AARC Clinical Practice Guideline: Incentive Spirometry: 2011.
• Pryor, J. A., & Prasad, S. A. (2008). Physiotherapy for Respiratory and Cardiac Problems. Elsevier.