How long should you use a spirometer after surgery

Design of the studies

All included studies claimed to be RCTs.

Types of study participants

Celli 1984 assessed 172 participants (59 male and 113 female) with a mean age of 47 years.

Craven 1974 evaluated 70 participants (39 male and 31 female) with a mean age of 52.4 years. The authors of this study evaluated high‐risk patients, defined as smokers and those with chronic respiratory disease.

Dohi 1978 studied 64 participants with a mean age of 55.5 years; the gender of the participants was not reported.

Hall 1991 evaluated 876 participants (436 male and 440 female) with a mean age of 55.0 years.

Hall 1996 assessed 456 participants with a mean age of 51.8 years, of whom 155 (68 male and 87 female) were eligible.

Jung 1980 enrolled 126 individuals (29 male and 97 female) with a mean age of 40.7 years.

Kulkarni 2010 studied 80 randomized participants and 66 were analysed, their age and gender were not reported.

Lyager 1979 studied 103 participants (9 patients were excluded from the study and from the analysis); their gender and mean age were not reported.

O'Connor 1988 assessed 40 participants with a mean age of 23.0 years; the participants' gender was not reported.

Ricksten 1986 evaluated 43 participants (21 male and 22 female) with a mean age of 53.7 years.

Schwieger 1986 enrolled 40 participants (9 male and 31 female) with a mean age of 53.5 years.

Stock 1985 assessed 65 participants; their gender and mean age were not reported.

Types of intervention

In Celli 1984, the control group received no respiratory treatment (n = 44); the first intervention group received intermittent positive pressure breathing therapy (IPPB) at a pressure of 15 cm H2O for 15 minutes, four times daily (n = 45); the second intervention group received incentive spirometry (IS) with a visual signal to indicate that the volume goal was met (a 3 sec breathhold signal was used to sustain maximal inspiration) four times daily (n = 42); and the third intervention group undertook deep breathing exercises (DBE) under supervision for 15 minutes, four times daily (n = 41). All treatments were applied for a minimum of 10 breaths at volumes ranging from 100 to 1800 ml, starting at one half of the preoperative VC until at least 70% of the VC was achieved.

In the Craven 1974 study the interventions were IS (n = 35) versus preoperative physiotherapy (twice a day, or more frequently if clinically indicated) (n = 35). Patients in the IS group received no chest physiotherapy but they received preoperative instructions about how to use the spirometer and practised using it. Postoperatively the IS group was encouraged to use the machine at least 10 times each hour for the first five postoperative days.

In the Dohi 1978 study the intervention groups were: (1) deep breathing using an incentive spirometric three‐ball, flow‐measuring device (Triflo), for five consecutive postoperative days five times every hour for about eight waking hours daily (n = 34, of whom only 23 underwent upper abdominal surgery); and (2) standard episodic IPPB (0.5 ml of a solution (Bronkosol) containing isoetharine hydrochloride and phenylephrine hydrochloride and 4.5 ml of saline) as the control group (n = 30, of whom only 13 underwent upper abdominal surgery). Each treatment lasted 15 minutes, averaging four treatments per day. In the Hall 1991 study, patients received an Airx incentive spirometer fitted with a one‐way valve (Airlife Inc, California, USA) which the patients were initially instructed on the use of (n = 431) (patients were encouraged to take slow maximal inspirations and to hold each breath for as long as possible) or chest physiotherapy (CP) (n = 445): 115 (IS) and 104 (CP); upper transverse or oblique incision: 129 (IS) and 116 (CP); upper vertical incision: 37 (IS) and 55 (CP). In Hall 1996, patients were randomized to receive either deep breathing therapy, where they were seen once and encouraged to take 10 deep breaths each hour, or IS, where they were provided with a laminated information sheet and an Airx incentive spirometer fitted with a one‐way valve (Airlife Inc, California, USA) that they used at least 10 times each hour by taking slow maximal inspirations and holding each breath for as long as possible.

In Jung 1980, one group was prescribed IPPB (n = 36) set at 15 cm H2O; the second group was prescribed resistance breathing used as often as possible (using a blow glove) (n = 45); and the third group was prescribed sustained maximal inhalations using an incentive spirometer (Spirocare) (n = 45) with a preset volume goal between 1400 and 1750 ml, which was to be held for three seconds using the breath‐hold signal incorporated into the spirometer. All patients received instructions on the use of the assigned device. Each treatment was undertaken four times daily, spread out during the waking hours, for 15 to 20 minutes through to the third postoperative day. No attempt was made to assure an absolute minimum number of breaths with any of the devices.

In Kulkarni 2010, the patients were divided in four groups: group A (n = 20), no training; group B (n = 20), deep breathing exercises; group C (n = 20), IS (Spiroball); and group D (n = 20), inspiratory muscle training (IMT) (patients were trained with Powerbreathe). In the postoperative period there were 14 lost to follow‐up: group A (n = 3), group B (n = 3), group C (n = 5), and group D (n = 3). Patients were expected to train twice daily, each session lasting 15 min, for two weeks minimum up to the day before surgery. They were also instructed in the technique by the researcher. The initial device resistance loading was set to 20% to 30% of baseline maximal inspiratory pressure (MIP) and according to ease of use in the first session. The load varied from one to nine and was increased incrementally by half a level daily for the first week.

In Lyager 1979, the patients were divided into two groups: the Bartlett group (exercise repeated at least four times per hour, starting the morning of the first postoperative day and continuing up to the end of the fourth day), and a control group. Patients in both groups received respiratory physiotherapy.

In O'Connor 1988, there were two groups: patients in one group used an IS as part of their postoperative chest physiotherapy (n = 20), those in the other group received routine postoperative physiotherapy (n = 20). Patients were encouraged to inhale maximally and the leak on the IS was adjusted to maintain the ball at the top of the tube for three seconds, three times every hour, postoperatively.

In Ricksten 1986, the three groups received: (1) deep‐breathing exercises by taking 30 sustained maximal inspirations every waking hour with the aid of a deep‐breathing exerciser (Triflo), (2) periodic continuous positive airway pressure (CPAP) via a face mask for 30 breaths every waking hour with a positive end‐expiratory pressure of 10 to 15 cm H2O, or (3) a positive expiratory pressure (PEEP) for 30 breaths every waking hour. The patients were trained preoperatively with individually chosen expiratory resistances. Treatment was started one hour after surgery and was continued for three postoperative days.

Schwieger 1986 randomized the patients to an IS group (n = 20) or a control group (n = 20) where patients did not receive any respiratory treatment before or after surgery. In the IS group, patients were trained before surgery with a volumetric incentive spirometer (Inspiron). The treatment started on the day of surgery and it consisted of increasingly deep and prolonged inspirations with the IS for five minutes hourly, at least 12 times per day, during the first three days after surgery.

In Stock 1985, there were three groups: (1) coughing and deep‐breathing group (CDB) (n = 20), (2) IS group (n = 22), and (3) the CPAP group (n = 23). All treatments lasted 15 minutes and were delivered every two hours during waking hours, starting from four to 72 hours after the operation. The IS device was adjusted to contain from 200 to 2000 ml to keep the bulb lit for three seconds. If inspiratory effort improved during the 15 minutes treatment, the volume was increased.

Types of outcome measures

Celli 1984 measured the patients' weight, height, temperature, heart rate, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), forced expiratory flow from 25% to 75% of vital capacity (VC), postoperative pulmonary complications, and length of stay in hospital.

Craven 1974 assessed pulmonary complications, temperature, pulse, respiratory rate, production of sputum, and recorded the use of analgesics.

Dohi 1978 measured FEV1, FVC, peak expiratory flow rate, and pulmonary complications.

Hall 1991 evaluated pulmonary complications, arterial blood gas analysis, and length of hospital stay.

Hall 1996 assessed respiratory complications and the time that staff devoted to prophylactic respiratory therapy.

Jung 1980 measured the presence of fever, increased respiratory rate, cough and sputum, abnormalities on auscultation of the chest, and pulmonary atelectasis.

Kulkarni 2010 measured patients' physical ability, pain score, discharge date, and the respiratory variables. Primary outcomes were absolute and relative change in all respiratory variables while secondary outcomes included length of stay, time in intensive care unit (ICU) postoperatively, time on a ventilator, respiratory rates, oxygen saturations, proven respiratory infections, and other pulmonary complications.

Lyager 1979 studied the severity of coughing, expectoration, and dyspnoea; the degree of mobility; arterial blood oxygenation and respiratory rate; pulse rate; body temperature; and carried out auscultation of the lungs. They recorded the degree of atelectasis, infiltration, stasis, and pleural effusion.

O'Connor 1988 evaluated pulmonary complications (cough, wheeze, basal crepitations, bronchial breathing), FEV1, FVC, arterial blood gas analysis, and length of hospital stay.

Ricksten 1986 assessed arterial blood gases, alveolar‐arteriolar oxygen difference, and peak expiratory flow.

Schwieger 1986 studied arterial blood gas analyses, body temperature, white blood cell count (WBC) and differential cell count, FVC, and FEV1, atelectasis and pulmonary complications.

Stock 1985 measured atelectasis, FVC, and FEV1.

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