Sweity 

et al. J Cardiothorac Surg (2021) 16:241

https://doi.org/10.1186/s13019-021-01628-2

RESEARCH ARTICLE Open Access

Preoperative incentive spirometry

for preventing postoperative pulmonary
complications in patients undergoing coronary
artery bypass graft surgery: a prospective,
randomized controlled trial
Essa M. Sweity1,2*  , Aidah A. Alkaissi3, Wafiq Othman4 and Ahmad Salahat1 

Abstract 
Background:  Postoperative pulmonary complications (PPCs) often occur after cardiac operations and are a leading
cause of morbidity, inhibit oxygenation, and increase hospital length of stay and mortality. Although clinical evidence
for PPCs prevention is often unclear and crucial, measures occur to reduce PPCs. One device usually used for this
reason is incentive spirometry (IS). The aim of the study is to evaluate the effect of preoperative incentive spirometry
to prevent postoperative pulmonary complications, improve postoperative oxygenation, and decrease hospital stay
following coronary artery bypass graft (CABG) surgery patients.
Methods:  This was a clinical randomized prospective study. A total of 80 patients were selected as candidates for
CABG at An-Najah National University Hospital, Nablus-Palestine. Patients had been randomly assigned into two
groups: incentive spirometry group (IS), SI performed before surgery (study group) and control group, preoperative
spirometry was not performed. The 40 patients in each group received the same protocol of anesthesia and ventila-
tion in the operating room.
Result:  The study findings showed a significant difference between the IS and control groups in the incidence of
postoperative atelectasis. There were 8 patients (20.0%) in IS group and 17 patients (42.5%) in the control group
(p = 0.03). Mechanical ventilation duration was significantly less in IS group. The median was four hours versus six
hours in the control group (p < 0.001). Hospital length of stay was significantly less in IS group, and the median was
six days versus seven days in the control group (p < 0.001). The median of the amount of arterial blood oxygen and
oxygen saturation was significantly improved in the IS group (p < 0.005).
Conclusion:  Preoperative incentive spirometry for two days along with the exercise of deep breathing, encour-
aged coughing, and early ambulation following CABG are in connection with prevention and decreased incidence of
atelectasis, hospital stay, mechanical ventilation duration and improved postoperative oxygenation with better pain
control. A difference that can be considered both significant and clinically relevant.

*Correspondence: [email protected]; [email protected]

1
Faculty of Graduate Studies, An-Najah National University, Nablus 44839,
Palestine
Full list of author information is available at the end of the article

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Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 2 of 11

Trial registration Thai Clinical Trials Registry: TCTR20201020005. Registered 17 October 2020—retrospectively
registered.
Keywords:  Incentive spirometry, Postoperative pulmonary complications, Atelectasis, Oxygenation, Ventilation time,
Coronary artery bypass grafting, CABG, Length of stay

Introduction Although clinical evidence regarding PPC preven-

Coronary artery disease (CAD) is the leading cause of tion is often unclear, crucial measures occur to reduce
death and disability worldwide [1]. Therefore, coronary PPCs. These include carefully individualized strategies
artery bypass grafting (CABG) is indicated for patients for preventing atelectasis and aspiration of oral secre-
with angina and suitable coronary anatomy, especially tions, increasing the patient’s ability to mobilize, expec-
those with stenosis of the left main coronary artery or torate secretions and restore functional residual capacity
patients with the multivessel disease [2]. [14]. In addition, several measures are applied to prevent
Postoperative pulmonary complications (PPCs) are PPCs, such as deep-breathing exercises, that IS, early
a frequent incident following cardiac, thoracic, and ambulation, and positive airway pressure [15, 16].
abdominal surgeries [3]. PPCs are widespread follow- Incentive spirometry (IS) is one tool frequently used for
ing CABG surgery, and the incidence is between 30 this purpose [3]. The IS is a handheld device used postop-
and 60% [4]. PPC complications contribute significantly erative to reach effective inspiration. Patients practicing
to morbidity, mortality, and hospitalization costs [5]. IS provide visual and positive feedback after inhaling at a
These complications include atelectasis, pulmonary determined flow volume rate and holding the inflation for
infections such as pneumonia and bronchitis, pleural at least 3 s [17]. IS intended to mimic normal sighing or
effusion, pulmonary edema, and respiratory insuffi- yawning by supporting the patient to take long and slow
ciency [6]. deep breaths. This reduces pleural tension, supporting
Atelectasis is a highly prevalent complication following enhanced lung expansibility and improving ventilation-
coronary artery bypass graft (CABG) surgery [7]. There is perfusion. In addition, atelectasis may be prevented or
no clear cause yet for atelectasis, but several factors may reversed when the procedure is repeated regularly [18].
contribute, such as impairment in the function of the dia- IS was found to decrease the incidence of PPCs and
phragm, general anaesthesia ‘abdominal distension, chest length of stay after upper abdominal surgery [19]. By
wall shift, pain, and pleural effusions [8]. contrast, many study publications have questioned its
The pain and postoperative fear associated with effectiveness [20, 21].
changes in lung mechanics resulting from the surgery Monitoring, instruction and teaching the patient how
affect the performance of periodic deep inspiration and to use the IS are the responsibility of nursing and res-
effective cough, allowing the accumulation of secretion, piratory therapy staff. Respiratory therapy that involves
alveolar collapse, and changes in gas exchange [9]. periods of IS each day in addition to deep-breathing
Shaban et  al. [10] evaluated the effect of respiratory applications, guided coughing, early mobilization, and
exercise in acute respiratory complications and the pain control can reduce the incidence of PPCs [22]. In
length of time patient hospitalization undergoing coro- addition, incentive spirometry may prevent PPCs in
nary artery bypass surgery by video teaching pre-and patients following CABG surgery [12].
postoperatively and revealed that the significant dif- Applications of deep breathing are shown to reduce
ference in the incidence rate of atelectasis decreased, the occurrence and severity of PPCs, such as pneumo-
concurrent with decreased hospital length of stay. nia and atelectasis. Through application instruction, the
Moreover, Oshvandi et  al. [11] and Yánez-Brage et  al. nurse clarifies and displays how to take a deep and grad-
[12] reported that the preoperative respiratory exer- ual breath and exhale gradually, three to five times every
cises include deep breathing, effective coughing and 1–2 h. Patients who carried out deep-breathing exercises
use, motivational incentive spirometry (incentive had improved pulmonary function in contrast with non-
spirometry, deep-breathing exercises, assisted cough- practicing groups [23].
ing and early ambulation) compared to normal perfor- Afrasiabi et  al. conducted a study about the influence
mance and the routine performed in the hospital, in of IS on the oxygenation status of arterial blood gases fol-
reduction atelectasis is more effective after coronary lowing a CABG operation. Throughout six h after Extu-
artery bypass graft surgery. In contrast, Freitas et  al. bation, the patient was handled, IS and preoperative, one
revealed that there is no benefit of IS decreasing PPCs h, and seven h after Extubation with arterial blood gases
in patients following CABG surgery [13]. [R] obtained. The researcher revealed that there was no
 Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 3 of 11

significant benefit in oxygenation status measured by Study setting and population

ABG’s after using IS [24]. Freitas et  al., Carvalho et  al., The study was conducted at AN Najah National Univer-
Eltorai et  al., and Overend et  al. have declared that, to sity Hospital. Data was collected from CCU and Inter-
date, there is no evidence to support the practice of IS mediate CCU wards. An-Najah National University
to decrease PPCs. Although IS is still usually requested Hospital has 200 beds, 5 beds for CCU and 16 beds for
to reduce PPCs, despite the narrow evidence to support Intermediate CCU. It is a non-profit hospital, located in
its advantages and the absence of a harmonized proto- the Northern West Bank, Palestine.
col, and they recommend that additional research is nec- Participants are adult patients scheduled for coronary
essary to clarify this issue [13, 20, 21, 25]. Agostini and artery bypass surgery, aged 18 or older, and patients
Singh differ from this opinion and have stated that this who were well motivated and compliant.
practice can improve pulmonary function [26].
Preoperative education gives health-related infor-
mation for patients, which prepares them for surgery Sample and sampling
and helps to decrease the development of PPCs [27]. To investigate the optimal sample magnitude for the
In numerous studies, it is suggested that postopera- trial that safeguards an adequate effect to identify sta-
tive incentive spirometry is practiced to decrease PPCs tistical significance, the effect of the trial was estimated
and decrease the length of stay (LOS), but the success at 80 percent power, with alpha levels at (p ≤ 0.05).
of postoperative incentive spirometry is dependent not Sample magnitude was computed as 37 patients for
only on the postoperative, but also the preoperative each group by using a formula (i.e., Pocock’s sample size
period, which has been shown to improve oxygenation, formula) that can be directly applied for comparison of
decrease the incidence of PPCs and to decrease hospital proportions P1 and P2 in two equally sized groups. To
LOS [28, 29]. and agreed with them Moradyan et al. [30] raise the potential of the current trial, we recruited 40
who revealed that receiving planned breathing exercises, patients in every group as has also been done in early
including deep-breathing exercises, incentive spirometry studies.
and directed cough manoeuvres have better oxygena-
tion after coronary artery bypass surgery. Another study
has shown that the rate of pneumonia and atelectasis Inclusion and exclusion criteria
reduced with breathing exercise and IS in obese patients Inclusion 18 years or older, scheduled to have coronary
prior to CABG surgery [31]. By contrast, Moradian et al. artery bypass grafting (CABG) and patients who were
[32] revealed that preoperative breathing exercise with well motivated and compliant.
incentive spirometry does not reduce pulmonary compli- Exclusion Patients who are expected not to be able to
cations and Hypoxemia. IS training before and after the conduct or comply with IS, such as patients with cog-
operation significantly improved lung inspiratory capac- nitive or neurological deficits, patients with coexisting
ity and arterial oxygenation in CABG patients [33]. acute or chronic respiratory disorders, patients unable
Since PPCs exhibit elevated rates of hospital costs, to understand or show the proper use of the incen-
morbidity, mortality, and increased length of hospital tive spirometer, patients who cannot be instructed
stay following CABG surgery, it is evident that it is essen- or supervised to assure appropriate use of the device,
tial to discuss the use of IS preoperatively to reduce PPCs patients in whom cooperation is absent or patients
and to decrease postoperative length of stay in the inten- unable to understand or demonstrate proper use of the
sive coronary care unit (ICCU) and in the hospital. The device, patients who are confused or delirious, patients
study aims to evaluate the effect of preoperative incen- undergoing any other surgery along with CABG, hav-
tive spirometry in preventing postoperative pulmonary ing prolonged mechanical ventilation (more than
complications, improving postoperative oxygenation, and 24  h) or re-intubation, patients undergoing emergency
decreasing the length of stay at the hospital in patients CABG surgery, chronic obstructive pulmonary disease
following CABG surgery. (COPD), asthma, restrictive lung disease, preopera-
tive major chest infection e.g. pulmonary tuberculo-
sis, chest deformities such as pectus carinatum, pectus
Materials and methods excavatum, thoracolumbar scoliosis, diaphragmatic
Study design hernias diagnosed on history.
The study was conducted as prospective cohort, rand- The Consort diagram of patient screening and alloca-
omized controlled trial (RCT). This design was adopted tion (Fig. 1) showed the patients excluded from the study
due the strength of the hierarchy of scientific evidence, in the result section. Moreover, all patients who met the
namely, reduced bias and more accurate results. criteria were involved and continued the study.
Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 4 of 11

Fig. 1  Consort diagram of patient screening and allocation

Randomization Measured outcomes

The participants who met the inclusion criteria were ran- The primary outcome was defined as respiratory com-
domized into two groups according to a randomization plications that occur within 48–72  h following surgery,
list formatted by www.​rando​mizat​ion.​com. which includes: atelectasis, pneumonia, pleural effu-
Group 1: Incentive spirometry was utilized by the sion, and Pneumothorax, which is measured by x-ray
patient with ten breaths, six times per day for a period and clinical signs and symptoms [34]. Chest X-ray was
of 10 min in every session with a breathing technique for examined by the radiologist for all patients and decided if
two days preoperatively. The patients were taught how atelectasis is present or not. However, the radiologist did
to use IS by a nurse who would not be involved in the not mention the grade or severity of the atelectasis, but
patient’s postoperative care. (Experimental group) (IS). they divided them to is present if atelectasis present or
Group 2: No IS preoperatively, only IS postoperatively not, also knowing that the radiologist was blinded about
(Control Group). the intervention or control group, also atelectasis defined
as the collapse of a part of or the entire lung, which may
be acute or chronic. This research refers to the charac-
Blindness ters such as X-ray, tracheal mediastinal shift deviation;
The patients, health care providers included in the patient reduced respiratory activity; diminished breath sounds;
care are unaware of the treatment group allocation. displacement of the trachea to the affected side; new
To ensure that the patients, the surgeon and the radi- parenchymal thickening surrounded by hyperinflated
ologist were blind to the treatment group before the lung [14].
study begins. The patients, surgeon, and radiologist were Secondary outcomes included hospital length of stay
unaware of IS group and the surgeries performed by the that was calculated by subtracting the day of admission
same surgeon. The radiologist was also assessing the from the day of discharge [35]. Mechanical ventilation
X-ray and wrote about all X-rays for all patients. duration in hours, oxygenation status by measuring Pao2
 Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 5 of 11

and SaO2 by ABG’s, and pain control using a numerical Thoracic x-rays were taken during the preoperative
pain scale. period and immediately following surgery in the intensive
cardiac care unit (ICCU), on the ward, once the drains
had been removed (48 h after surgery), and on discharge
Measurement and data collection procedure from the hospital. X-ray examinations were performed at
The participants who met the inclusion criteria and ran- the same frequency for all patients in both groups.
domized to the intervention group were given a flow-
based incentive spirometer and asked to use spirometry Anaesthesia protocol
with deep-breathing exercise 2  days preoperatively until (AN-Najah National University Hospital protocol).
surgery. They were asked to hold the spirometer in All patients in both groups received the same anaesthe-
the upright position, place their lips tightly across the sia technique and ventilation in the operation room.
spirometer mouthpiece, and then they were asked to A standard induction for cardiac anaesthesia started
slowly inhale air into the lungs to raise the ball to the tar- with a facial mask inhaling sevoflurane 0–8% in 100%
get position. After that, the mouthpiece was removed, oxygen and fresh gas flow of 3  L/min for 5  min. After
and patients were asked to hold their breath for at least that, patients were given IV anaesthesia Propofol 2  mg/
5 s, followed by normal expiration. Incentive spirometry kg IV and tracheal intubation was facilitated with rocu-
was done with ten breaths, six times per day for a period ronium 1.5–2  mg/kg with fentanyl 2–20  mcg/kg/dose
of 10  min every session before surgery, according to lit- initially.
erature and An-Najah National University hospital.
All patients who enrolled in the intervention were Maintenance of anaesthesia
100% compliant with preoperative IS after teaching him Anaesthesia was maintained with sevoflurane 0–3% in
how to use the IS; also, reminder was used by nurses by 50% oxygen and 50% air. Neuromuscular blockade was
a drug sheet that wrote by the doctors every 4  h. Also, maintained with increments of atracurium with this
the nurses ensured the patients’ practice of IS, knowing equation: 0.3(dose)*kg/4(concentration/ml) = ml/hr, fen-
that all patients did not know about preoperative IS tend tanyle was used to provide intraoperative analgesia with
to be healthier as what literature previously said it is no this equation: 2(dose)*kg/20(concentration/ml)  = ml/hr
benefit. as 1–2 mcg/kg/hr maintenance.
Observations and hemodynamic parameters were For special cases like decreased ejection fraction and
measured preoperatively and postoperatively. For both left main coronary disease, etomidate 0.3–0.6 mg/kg was
groups, study observations were recorded every 6  h. used.
Both groups postoperative received the same interven-
tion: the exercises began on the morning after surgery Ethical considerations
with incentive spirometry, deep-breathing exercise and The institutional Review Board (IRB) of An-Najah
physiotherapy after Extubation, and early mobilization, National University approved the study. Consent forms
in accordance with An-Najah University Hospital pro- were obtained from the patients prior to participation
tocol. A datasheet containing the following information and the study was registered in the Thai Clinical Tri-
was filled out for each patient: name, age; height; weight; als Registry (No. TCTR20201020005). All patients were
body mass index, respiratory status, medical history, given both verbal and written information about the aim
presence of respiratory complications, duration of MV, and objectives of the study before considering participa-
and numerical pain scale and hospital length of stay. tion in the study. The study was conducted in accordance
The data collection sheet was prepared after going with the World Health Organization Declaration on the
through the linked literature and with the supervision Ethical Principles of Helsinki for Medical Research on
of experts in the field. Content validity is defined as “the Humans (2013) [39].
degree to which objects in an instrument reflect the con-
tent universe to which the instrument will be generalized Analyses
[36]. Content validity was applied while the datasheet The data were analysed with SPSS version 22 for Win-
was developed to ensure that it included all essential dows (IBM Corp., Armonk, NY, USA). Data normality
items [37, 38]. The assessment method for determining was tested using Kolmogorov–Smirnov test. The data
the validity of the data sheet included literature reviews were not normally distributed. Thus, nonparametric sta-
and then follow-ups with evaluation by expert judges or tistical tests were used. The Scale data are expressed as
panels (two intensivists, one anesthesiologist, and three the median (quartile 1 [Q1]–quartile 3 [Q3]). The groups
nurses in critical care), and all experts’ suggestions were were compared with the Mann–Whitney U Test. Cat-
taken into account. egorical variables (YES/NO questions) were statistically
Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 6 of 11

analysed with Chi-square tests have been used. A p Respiratory complication

value ≤ of 0.05 was considered to indicate a statistically Figure  2 shows the respiratory complications of atelec-
significant difference. tasis among the IS Group and the Control Group. On
the operation day, there was no atelectasis diagnosed
Results in either group. On the first day, of the 22 patients with
One hundred clients were assessed for eligibility, but 20 atelectasis, seven were in the IS group and 15 in the Con-
were excluded, 15 did not meet the inclusion criteria, trol Group, showing statistically significant differences (p
three declined to participate, and two converted to PCI. value = 0.045). On the next day, the number of patients
The patients who did not meet the criteria switched to in the Control Group with atelectasis was 17, and in the
the hospital routine (using incentive spirometry with IS group, it was 8, with statistically significant differences
deep-breathing exercise postoperatively only). The (p value = 0.030). Furthermore, the third day showed four
remaining 80 clients were enrolled in the study and ran- clients with atelectasis in the Control Group and zero
domly allocated into two groups, as shown in the Con- patients in the IS group, with statistically significant dif-
sort diagram (Fig. 1). ferences (p value = 0.040). On the other hand, there were
no statistically significant differences between the groups
Socio‑demographic and medical history characteristics in other respiratory complications.
of the study participants
Demographic data were comparable between the two
groups (Table  1). All patients in the two groups were
comparable in terms of age, gender, comorbidity, smok-
ing, and BMI. Hemodynamic parameters and other
observations were recorded before the operation, post-
operatively, and three days postoperatively. There are
no significant differences between the IS Group and the
Control Group in all general characteristics of patients
exhibited at the table 0.05 level (p value > 0.05).

Fig. 2  Percentage rate of atelectasis occurrence among IS and

control groups. *p value of ≤ 0.05

Table 1  Demographic data and history

Variable Total (Mean ± SD) IS group (Mean ± SD) Control group (Mean ± SD) p value

Age 54.3 ± 4.5 54.4 ± 3.8 54.3 ± 5.1 0.961

Variable Yes/no IS group n (%) Control group n (%) p value

Gender Male 22 (55.0%) 21 (52.5%) 0.823

Female 18 (45.0%) 19 (47.5%)
DM Yes 17 (42.5%) 20 (50.0%) 0.501
No 23 (57.5%) 20 (50%)
HTN Yes 15 (37.5%) 15 (37.5%) > 0.999
No 25 (62.5%) 25 (62.5%)
IHD Yes 18 (45.0%) 15 (37.5%) 0.496
No 22 (55.0%) 25 (62.5%)
PCI Yes 5 (12.5%) 8 (20.0%) 0.363
No 35 (87.5%) 32 (80.0%)
Smoking Yes 14 (35.0%) 16 (40.0%) 0.644
No 26 (65.0%) 24 (60.0%)
BMI 26.5 ± 2.6 26.4 ± 2.1 0.967
BMI category Normal weight 12 (30.0%) 9 (22.5%) 0.727
Overweight 24 (60.0%) 28 (70.0%)
Obesity 4 (10.0%) 3 (7.5%)
 Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 7 of 11

Fig. 3  Graphical comparison of median length of stay at the hospital

per day between IS and control group. *p value of ≤ 0.05 Fig. 5  Graphical comparison of median partial pressure of oxygen
(Pao2) between IS and control groups. *p value of ≤ 0.05

Fig. 4  Graphical comparison of median duration of mechanical

ventilation per hour between IS and control groups. *p value of ≤ 0.05

Fig. 6  Graphical comparison of median oxygen saturation of arterial

Length of stay blood (SaO2%) between IS and control groups. *p value of ≤ 0.05
Figure  3 shows that there are significant differences
between the IS Group and the Control Group in the
length of stay in the intensive cardiac care unit (ICCU), On the other hand, there were no significant differences
intermediate cardiac care unit (IMCCU), and hospital between the groups pre-and postoperatively with (p
discharge (p value =  < 0.001). The IS Group average was value = 0.900 and 0.149), respectively.
three days in ICCU, two and a half days in IMCCU. In
contrast, the Control Group average was four days in
ICCU and three days in IMCCU. Oxygen saturation of arterial blood (SaO2%)
Figure  6 shows that there are significant differences
Duration of mechanical ventilation between the IS Group and the Control Group in the
Figure  4 shows that there are significant differences oxygen saturation of arterial blood (Sao2), with obvious
between the IS Group and the Control Group in the differences, as shown in the p value in all postopera-
duration of time spent in mechanical ventilation in the tive measurement times. On the other hand, there were
intensive cardiac care unit (ICCU). Patients in the IS no significant differences between the preoperatively
Group spent 4  h, while patients in the Control Group groups (p value = 0.335).
spent 6  h (p value =  < 0.001). The median hours spent
was 5  h. However, the incidence of re-intubation was
(0.0%) with (p value =  > 0.999). Numerical rating scales (NRS) pain scale
Figure  7 shows that there were significant differences
Oxygenation between the IS Group and the Control Group in the
The partial pressure of oxygen (Pao2) numerical rating scale (NRS) pain scale, with obvious
Figure  5 shows significant differences between the IS less pain in the IS Group than the control when using
Group and the Control Group in the partial pressure the same analgesic plan, as shown in the p value below
of oxygen (Pao2), with obvious improvement in Pao2 in in all measurements at all times except at 12  h. In the
the IS Group, as shown in the p value from 6 to 90  h. NRS, scores ≤ 5 corresponded to mild, 6–7 to moder-
ate, and ≥ 8 corresponded to severe pain.
Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 8 of 11

was conducted on 263 patients and revealed that preop-

erative physiotherapy (involving incentive spirometry,
deep-breathing exercises, assisted coughing and early
ambulation) after off-pump CABG surgery was related to
a lower incidence of atelectasis.
Conversely, the current study is inconsistent with
a study conducted by Moradian et  al. [32]. This study
examined 100 participants and found no significant dif-
ferences between the IS and control groups in terms of
atelectasis and hypoxemia (p value > 0.05). Freitas et  al.
[13] also revealed no evidence of a difference between
Fig. 7  Graphical comparison of the median numerical rating scale
groups in the incidence of PPCs with IS and treatment
(NRS) pain scale between IS and control groups. *p value of ≤ 0.05
with physical therapy, positive-pressure breathing tech-
niques, active cycle of breathing, or preoperative patient
education and worse pulmonary function and arterial
Discussion oxygenation. Eltorai et  al. [25] investigated the clini-
The results of this study indicate that IS was used pre- cal effectiveness of incentive spirometry and found that
operatively for patients with CABG surgery to reduce there was narrow evidence to support its advantages and
postoperative atelectasis, length of hospital stay, and an absence of a harmonized protocols for its use. In addi-
improved postoperative oxygenation. tion, Overend et  al. [21] conducted a systematic review
study and concluded that evidence does not support the
use of IS for decreasing the incidence of PPCs.
The effect of preoperative incentive spirometry
on atelectasis
In the current study, there was a significant decrease in The effect of preoperative incentive spirometry
the incidence of atelectasis in the IS Group. This finding on oxygenation
is consistent with Diken and Özyalçın [31], who con- The current results showed a significant improvement in
ducted an RCT that involved 108 patients divided into Pao2, Sao2, and SPO2 in the IS Group compared to the
two groups: IS preoperative and routine care for control, Control Group. These results are consistent with Fayyaz
with a body mass index over 30 kg/m2 and without pre- et al. [28], where preoperative spirometry had improved
vious pulmonary disease. In Diken and Özyalçın’s study, postoperative oxygenation in the IS group to 97.29 while
patients with atelectasis were predominantly higher in the control group was 93.27. These results are in line
the Control Group compared to the IS Group (18 vs. 7 with Yazdemik et  al. [29], who concluded that incentive
patients, respectively) (p =  0.0036). The current find- spirometry caused a remarkable improvement of Pao2,
ings also agree with Gilani et al. [40], who conducted an Sao2, and SPO2. Another study conducted by Moradyan
RCT that showed the incidence of postoperative atelec- et  al. [30] corresponds to the current study results and
tasis was 14.10% in Group I (IS) and 27.10% in Group II revealed that protocols for breathing exercises (deep
patients (control) (p = 0.04). Moreover, the current study breathing, incentive spirometry, and directed maneu-
results are consistent with Oshvandi et al. [11], who was vers) could improve PaO2 and SaO2. In contrast, Balan-
showed that the occurrence of atelectasis, respiratory diuk and Kozlov [33] revealed that the use of an incentive
status, dyspnea, and sweating showed a significant dif- spirometer preoperatively for cardiac surgery signifi-
ference between the IS and control groups at all hours cantly improved arterial oxygenation.
after surgery (p < 0.001). Furthermore, the results are also Freitas et  al. [13] presented results that contradict
in agreement with Shaban et  al. [10], who showed the the current results. They found no differences between
incidence rate of atelectasis in the experimental group the study groups in terms of incentive spirometry used
was (26.7%), less than the control group (56.7%) with and found poorer lung function and status of arterial
(p = 0.01). In addition, the study results also agree with oxygenation competed with those treated with posi-
Nardi et al. [19], who revealed that better clinical results tive pressure ventilation. Diken and Özyalçın [31] also
for respiratory and musculoskeletal function were found disagree with our study results after conducting RCT
in the groups preoperatively treated with physiothera- with the two groups and showed no change in oxygena-
peutic protocols immediately before as well as after car- tion status for both groups. Even Afrasiabi et  al. [24]
diac surgery. Just the same results were confirmed by reported that incentive spirometry had no significant
Yánez-Brage et al. [12] in their observational study, which effect on the improvement in postoperative oxygenation.
In addition, Yánez-Brage et al. [12] also reported that the
 Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 9 of 11

improvement in postoperative oxygenation using incen- observed during the time of mechanical ventilation
tive spirometry is not permanent; this improvement is between the study groups.
reversible after a short period of time. Carvalho et  al.
[20] in a systematic review study, reviewed 30 studies in
relation to IS. They reported that there was no strong evi- The effect of preoperative incentive spirometry on pain
dence to support the use of IS after CABG, and there is a control
need for studies to clarify the effect and justify the use of The current results showed significant differences
this technique. between the incentive spirometry group and the control
group in the numerical rating scale (NRS) pain scale with
obvious pain in the IS group rather than control using the
The effect of preoperative incentive spirometry on hospital same analgesic plan as shown p value in all measurements
length of stay at all times except at 12  h. To consider NRS, scores ≤ 5
The current results showed that the incidence of hospital correspond to mild, 6–7 to moderate, and ≥ 8 to severe
length of stay for the IS Group was 6  days, while in the pain. However, deep breathing exercises and cough may
Control Group it was 7 days. ICU LOS for the IS Group cause pain to patients, but patients well educated about
was also reduced compared with the Control Group. This incentive spirometer preoperative will be less needed to
finding is consistent with Nardi et  al. [19] who revealed analgesia and better improvements in respiratory status.
that the hospital stay was further reduced in the IS This finding is agreed with Renault et al. [9], who report
group. In addition, Shaban et al. [10] reported the same that pain and postoperative fear are associated with
results when they declared that the hospital length of changes in lung mechanics that affect the performance
stay decreased for the IS group compared to the control of periodic deep inspiration and effective cough with
group. On the other hand, Fayyaz et  al. [28] presented effective spirometry, allowing the accumulation of secre-
results that contradict the current results. They revealed tion, alveolar collapse, and changes in gas exchange, early
that there were no differences between the groups in incentive to cough decreases pain and better control.
length of hospital stay.

The effect of preoperative incentive spirometry IS the clinical application, and what is new?

on mechanical ventilation time The current study demonstrated the clinical application
The current results showed significant differences and IS a protocol that showed important results in reduc-
between the two groups (IS and Control) regarding ing atelectasis occurrence in CABG patients. Meanwhile,
mechanical ventilation time (duration), which was 4  h some of the clinical trials question the effectiveness of
for the IS Group and 6  h for the Control Group. This IS use and why it is still prescribed to patients in differ-
finding is consistent with Gilani et  al. [40], who showed ent locations, especially after cardiac surgery [22, 25].
that mechanical ventilation time was significantly less This paper suggests the implication of this protocol in
in Group I patients (IS): it was 5.49 + 2.28  h versus intensive cardiac care units, especially with critical care
6.74 + 5.46 h in Group II patients (control) (p value 0.05). nurses.
This finding also agrees with Balandiuk and Kozlov [33], Proper preoperative incentive spirometry concurrent
who reported that a significant decrease in the dura- with deep breathing exercises and coughing every 4  h
tion of MV in the IS group was 7.3 h compared to 10.4 h as a new protocol will enhance and improve the respira-
(p < 0.05) in the control group. tory status, especially atelectasis with others improving
Moradian et  al. [32] presented results that contradict in patient’s status that leads to a better outcome and less
the current study results. They revealed that there were pain, however, patients covered with analgesics, but less
no differences between the groups in mechanical venti- use it.
lation time, with 10.5  h for the IS group and 11.5  h for
the control group. Yazdemik et al. [29] also reported the
same duration of mechanical ventilation in both groups Recommendations
following coronary artery bypass surgery, which means This study was performed on patients who received
there were no differences between the groups. Moreo- invective spirometry for two days preoperative and did
ver, Afrasiabi et al. [24] presented results that contradict not have lung problems. Therefore, it is recommended
the current study results. They found no differences in to conduct a clinical study to examine incentive spirom-
mechanical ventilation time between the study groups. etry with deep breathing and cough trials in patients who
Furthermore, Yánez-Brage et  al. [12] in an observa- will undergo CABG surgery with lung problems such as
tional study, showed that no statistical differences were chronic obstructive pulmonary disease and asthma.
Sweity et al. J Cardiothorac Surg (2021) 16:241 Page 10 of 11

Conclusions Received: 5 May 2021 Accepted: 16 August 2021

Preoperative incentive spirometry, along with deep
breathing exercises, assisted coughing, and early ambu-
lation after coronary bypass surgery is related to the
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