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Effects of Incentive Spirometry on Perceived Dyspnea in Patients Hospitalized with Pneumonia.

Dyspnea is a common symptom of pneumonia. This study found incentive spirometry (IS) was no more effective than placebo in preventing pulmonary complications in patients diagnosed with pneumonia. The cost effectiveness and clinical value of IS for pneumonia should be considered carefully.

Pneumonia is a frequently diagnosed condition with significant rates of morbidity and mortality (Mandell, 2015). Dyspnea, a distressing symptom of breathlessness that often leads patients to seek treatment, is a common clinical manifestation of pneumonia (Coccia, Palkowski, Schweitzer, Motoshi, & Ntusi, 2016). Dyspnea, defined as the awareness of having difficulty and discomfort with breathing (Coccia et al., 2016), is an individual and subjective experience (Coccia et al., 2016; Williams, Cafarella, Paquet, & Frith, 2015). Anxiety and fear related to pneumonia can exacerbate patients' experience of dyspnea and inhibit lung expansion, increase the risk of pulmonary complications, and lengthen recovery time (Williams et al., 2015).

Adjunct interventions that promote lung expansion and gas exchange in patients with pneumonia may reduce dyspnea and lower the risk of pulmonary complications. Incentive spirometry (IS) is a nonpharmacological intervention widely used to treat and prevent pulmonary complications during the postoperative period (Tyson, Kendig, Mabedi, Cairns & Charles, 2015). The IS device is used to increase lung expansion, decrease pleural pressure, and promote better gas exchange to prevent atelectasis and other respiratory complications (Paisani et al., 2013; Restrepo, Wettstein, Wittnebel, & Tracy, 2011). IS promotes deep breathing by providing patients with visual feedback on if they are able to meet the recommended inhalation volume (Paisani et al., 2013; Tyson et al., 2015).

The American Association for Respiratory Care Clinical Practice Guidelines Steering Committee conducted a systematic review of 54 clinical trials to update the organization's IS clinical practice guideline (Restrepo et al., 2011). Members found deep-breathing exercises provided the same benefit as IS in preventing postoperative pulmonary complications in preoperative and postoperative settings. Authors recommended IS should be used only in combination with deep-breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent postoperative pulmonary complications. Additionally, they recommended against the use of IS to prevent atelectasis in patients following upper abdominal surgery and coronary artery bypass graft surgery. The committee did not mention use of IS for treatment of pneumonia.


The primary purpose of this study was to compare the effects of IS use with a placebo-control activity on perceived dyspnea in patients hospitalized with pneumonia. The secondary purpose was to compare effects of IS use to placebo-control on vital capacity (VC) and oxygen saturation.

Literature Review

Databases searched were Pub Med, CINAHL, Ovid, and ProQuest Nursing. Search terms included incentive spirometry, pneumonia AND treatment, and dyspnea. At the time of the original literature review, investigators included research published 2006-2012. A subsequent review included research published 2006-2016. Both searches yielded minimal research regarding application of IS to patients admitted to the hospital with diagnosis of pneumonia. Most research was centered on the effectiveness of IS use in prevention of postoperative pulmonary complications, and results were mixed (Cassidy, Rosenkranz, McCabe, Rosen, & McAneny, 2013; Restrepo et al., 2011; Rollins et al., 2013; Tyson et al., 2015).

Tyson and colleagues (2015) studied the effect of IS use on pulmonary function following exploratory laparotomy, as measured by forced VC. This single-center randomized controlled trial (RCT) had a sample of 150 patients. The control group (n=75) received standard care (deep breathing and early ambulation) while the intervention group (n=75) received IS plus standard care. Results showed no statistically significant difference in pulmonary function following laparotomy for IS use versus standard care. Additionally, hospital length of stay did not differ between the groups. Researchers recommended against adding IS to the current standard of care in this resource-constrained environment.

Cassidy and co-authors (2013) developed an interprofessional pulmonary care program to reduce postoperative pulmonary complications for patients who had undergone general or vascular surgery over a 1-year period. The program emphasized IS use, coughing and deep breathing, oral care, ambulation three times daily, and head-of-bed elevation. Authors compared pulmonary outcomes before and after program implementation. Results showed a reduction in the incidence of postoperative pneumonia and unplanned intubation following implementation of the program. Because IS was one of many interventions included in the program, the role of IS was uncertain for preventing pulmonary complications.

Rollins and colleagues (2013) studied the impact of early IS use versus chest physiotherapy on the incidence of chest infection in patients undergoing laparoscopic donor nephrectomy. Their retrospective study had a sample of 84 patients at a single institution. IS use was taught to 45 of 84 donors before and after surgery. The other 39 patients received only chest physiotherapy postoperatively. In the group instructed on use of postoperative IS, no one developed a chest infection. Of the 39 patients who did not receive IS instruction, five developed a chest infection by microbiological or radiologic evidence (12.6%). Authors cautioned the effectiveness of IS may be less if its introduction is delayed. Some limitations noted in this study were the small sample size and retrospective review methodology.

In a systematic review, Freitas, Soares, Cardoso, and Atallah (2012) explored the effects of IS use compared to other prophylactic physiotherapies for preventing postoperative pulmonary complications in adults undergoing coronary artery bypass graft (CABG). The review included 592 subjects in seven RCTs published before 2011. Authors concluded there was no evidence of benefit from IS use in reducing pulmonary complications and decreasing the negative effects on pulmonary function in patients undergoing CABG compared to other physiotherapies (e.g., early bed mobility, ambulation, basic deep breathing, coughing exercises).

Significance of Research

The literature review for this study found mixed results regarding IS use for prevention of postoperative pulmonary complications. Moreover, no research was found regarding the use of IS as effective treatment for dyspnea or an adjunct intervention for pneumonia. Despite the lack of research to support IS use for pneumonia, it continues to be recommended as an appropriate intervention (Ignatavicius & Workman, 2015) and is included in the pneumonia clinical pathway for the authors' health system. When members of the research team approached several hospital pulmonologists regarding the rationale for using IS for treatment of pneumonia despite lack of evidence, they all theorized IS reduces dyspnea by promoting lung expansion. Respiratory therapists on the research team agreed with the pulmonologists and indicated they encourage its use by patients with pneumonia. Noting the gap in the literature on the use of IS for pneumonia, the research team developed a study to determine if IS was an effective treatment to reduce dyspnea in hospitalized patients with pneumonia. If IS was indeed an effective treatment for dyspnea, then it was agreed all patients with pneumonia should receive it.


Subjects and Setting

This study was conducted on a pulmonary unit in a large tertiary care hospital in the midwestern United States. Patients included in the study were at least age 18, admitted to the hospital with a diagnosis of pneumonia confirmed by chest x-ray, able to speak and understand English and follow instructions, and without physical limitations or medical conditions for which IS would be contraindicated. Patients were excluded if they were transferred from another inpatient unit, had orders for newly prescribed steroids or an increased dose from their baseline, had elevated B-type natriuretic peptide, required isolation precautions, received EZ positive airway pressure therapy, or required a Venturi mask or positive pressure ventilation during their hospitalization. The exclusion criteria were specified to reduce the influence of other factors on the study outcomes.

This study was approved by the hospital's Institutional Review Board (IRB) before data collection. All eligible patients were given a verbal explanation of the study's purpose as well as a written document with this information and contact information for the IRB and investigators. Patients who verbally agreed to participate were enrolled in the study.


This study had a 2 x 2 crossover randomized controlled design to compare the change in perceived dyspnea scores before and after IS use versus a placebo-control activity. The independent variable of interest was the treatment effect of IS versus placebo-control activity. The primary dependent variable was perceived dyspnea, which was explained to study participants as shortness of breath. Dyspnea was measured with a vertical Visual Analog Scale (VAS) ranging from 0 mm (no shortness of breath at all) to 100 mm (worst ever shortness of breath). Unidimensional tools such as the VAS are appropriate for assessing the effect of an intervention to relieve dyspnea (Thomas, Bausewein, Higginson, & Booth, 2011). Participants were asked to draw a horizontal line at a point on the vertical scale that best represented their level of perceived dyspnea.

VC and oxygen saturation also were measured as secondary dependent variables. For the purpose of this study, vital capacity was defined as the maximum volume exhaled following maximum inhalation. VC is an indication of the ability to breathe deeply, cough, and clear secretions from the airway (Patil & Desai, 2013). VC was measured using a Wright respirometer. Oxygen saturation was measured using a portable pulse oximeter.

A power analysis was calculated to detect the mean pre- and post intervention difference in perceived dyspnea on the VAS. Power of 0.8031 was predicted for the study involving 64 subjects (SD=20; p=0.05) to detect an average treatment difference of 10 points. To account for potential attrition, 67 patients were enrolled in the study.


Data were collected January 2013-August 2015. Upon enrollment, study participants were assigned to group 1 or group 2 using a computerized randomization scheme. Group 1 used the IS first, followed by a rest period of 1 hour, and then performed the placebo-control activity. Group two performed the placebo-control activity first, followed by a rest period of 1 hour, and then used the IS (see Figure 1). The placebo activity consisted of a word search puzzle. Measurements were taken immediately before each activity and 15 minutes after completion of each activity. The time spent in each activity was monitored so the amount of time spent on the word search puzzle was equivalent to that spent using the IS.

Descriptive treatment group mean change scores and within-group period stratified mean change scores were calculated for perceived dyspnea (see Tables 1 & 3). The higher the mark on the VAS, the worse the subject's dyspnea. Therefore, a negative change score (post-test minus pre-test score) indicated improvement and a positive change score indicated worsening of perceived dyspnea. Additionally, descriptive treatment group mean change scores and within-group period stratified mean change scores were calculated for VC and oxygen saturation (see Tables 2 & 4). Positive change scores (post-test minus pre-test score) indicated improvement and negative change scores indicated worsening of VC and oxygen saturation.

Linear models were used to test carry-over effect, period effect, and treatment effect on perceived dyspnea and VC. Significance level was set at 0.05.


Two subjects were eliminated from the analysis due to missing data, yielding a final sample of 65 (36 females, 29 males). Forty-nine (75.4%) were Caucasian, 15 (23.1%) were African American, and 1 (1.5%) was Asian. Range of participants' ages was 19-92 (mean age 67.63).

For each treatment period, VAS was measured before and after activity and VC was measured before and after activity three times, with the highest value used in the analysis measurement. Each subject thus had four measurements retained for data analysis (1st period prior VAS, 1st period post VAS, 2nd period prior VAS, 2nd period post VAS; and 1st period max prior VC, 1st period max post-VC, 2nd period max prior VC, 2nd period max post VC). The raw change values (change = post score minus pre score) under each period of VAS and max VC were included in the data analysis. Finally, for each subject, two measurements for VAS change and max VC change were used in model building (1st period VAS change, 2nd period VAS change; and 1st period max VC change, 2nd period max VC change).

No statistically significant differences were found in treatment effect between IS use and placebo on perceived dyspnea (p=0.19) or max VC (p=0.23). Oxygen saturation remained the same for every subject. No significant carry-over effects were found in analysis of dyspnea (p=0.30) or VC (p=0.24), meaning the effect of either activity (IS or placebo) performed in the first period did not carry over to the second period. This provided validation for the study design.

Discussion of Findings

This study demonstrated no difference in treatment effect between IS use and the placebo-control activity on patients' perceived dyspnea. In fact, the mean dyspnea VAS change scores following IS use trended positively (suggesting worsening), while trending negatively for the placebo (suggesting improvement) (see Table 2). Additionally, no differences were found in treatment effect between IS use and placebo-control on VC and oxygen saturation.


Generalizability of results is limited in part because the convenience sample was recruited from one pulmonary unit in a single metropolitan hospital. In addition, while rigorous exclusion criteria were employed to increase internal validity, this also limited the ability to generalize to other patients with pneumonia in different geographic areas. Finally, the majority of the sample was Caucasian, reducing generalizability to other ethnicities.

Nursing Implications

As patient advocates, nurses must be accountable for ensuring patients receive quality care based on evidence. Evidence is sparse in the literature to support the use of IS as an adjunct intervention for pneumonia-related dyspnea. In addition, results from this study suggested IS use provides no benefit over a placebo-control activity (word puzzle) in reducing perceived dyspnea, or improving VC and oxygen saturation in patients with pneumonia. Therefore, the lack of evidence supporting IS use should be considered when collaborating with healthcare providers, respiratory therapists, and patients to select adjunct interventions for pneumonia-related dyspnea.

Nurses and other healthcare providers must evaluate the cost effectiveness and value of implementing IS in the current climate of rising healthcare costs. Along with the cost of the IS device itself, other costs are associated with IS treatment. For example, nursing and respiratory therapy time is required to implement IS, which involves educating the patient on the correct use of IS, evaluating and documenting the patient's understanding of instructions, and following up to ensure proper use. Use of the IS device also requires a time commitment from the patient. Other evidence-based nonpharmacological interventions to improve dyspnea in patients with pneumonia should be considered.

Despite its frequency and impact on quality of life, dyspnea is not well understood (Coccia et al., 2016). Subjective in nature, it is difficult to quantify and treat appropriately. Moreover, dyspnea is associated with other symptoms, such as fear and anxiety (Chin & Booth, 2016). Clinicians are challenged further to implement interventions that target dyspnea specifically. Research on nonpharmacological interventions for dyspnea is lacking (Chin & Booth, 2016). A few interventions have been suggested in the palliative care literature, including fans to promote increased air circulation, cognitive behavioral and self-management techniques, pulmonary rehabilitation, energy conservation, breathing techniques, and positioning (Chin & Booth, 2016). Traditionally, nurses have implemented these types of interventions to lessen the sensation of dyspnea. For example, one study demonstrated significant decreases in patients' dyspnea when fans were directed toward their faces (Kamal, Maguire, Wheeler, Currow, & Abernethy, 2012). Anxiety reduction using cognitive behavioral therapy also can reduce dyspnea (Chin & Booth, 2016; Williams et al., 2015).

Recommendations for Future Research

Given the findings and limitations of this study, additional research should be conducted with a larger, more diverse sample and other nonpharmacological interventions. More evidence regarding the use of IS for patients with pneumonia is needed to ensure the best use of nursing time, most efficient use of healthcare resources, and best outcomes for patients. Other non-pharmacological interventions from the palliative care literature might be explored in patients with pneumonia who experience dyspnea. Interventions such as positioning and breathing techniques could be compared to a placebo-control activity in an inpatient setting to determine their effectiveness on dyspnea.


This study found no statistically significant differences in treatment effect between IS use and a placebo-control intervention on dyspnea, VC, or oxygen saturation in patients diagnosed with pneumonia. In other words, IS was no more effective than placebo. While more research is needed, results from this study provide some support for eliminating the use of IS as an adjunct intervention for patients with pneumonia. This study may facilitate discussion among practitioners regarding other nonpharmacological interventions that may be effective for treatment of dyspnea in patients with pneumonia.


Cassidy, M.R., Rosenkranz, P., McCabe, K., Rosen, J.E., & McAneny, D. (2013). I cough: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surgery, 148(8), 740-745.

Chin, C., & Booth, S. (2016). Managing breathlessness: A palliative care approach. Postgraduate Medicine, 92(1089), 393-400.

Coccia, C.B., Palkowski, G.H., Schweitzer, B., Motoshi, T., & Ntusi, N.A.B. (2016). Dyspnoea: Pathophysiology and a clinical approach. South African Medical Journal, 106(1), 32-36.

Freitas, E.R., Soares, B.G., Cardoso, J.R., & Atallah, A.N. (2012). Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. The Cochrane Database of Systematic Reviews, 9, CD004466. doi: 10.1002/ 14651858.CD004466.pub3

Ignatavicius, D., & Workman, M. (2015). Medical-surgical nursing: Patient-centered collaborative care (8th ed.). St. Louis, MO: Mosby Elsevier.

Kamal, A.H., Maguire, J.M., Wheeler, J.L., Currow, D.C., & Abernethy, A.P. (2012). Dyspnea review for the palliative care professional: Treatment goals and therapeutic options. Journal of Palliative Medicine, 15(1), 106-114.

Mandell, L. (2015). Community acquired pneumonia: An overview. Postgraduate Medicine, 127(6), 607-615.

Paisani, D.M., Lunardi, A.C., Silva, C.C., Porras, D.C., Tanaka, C., & Carvlho, C.R. (2013). Volume rather than flow incentive spirometry is effective in improving chest wall expansion and abdominal displacement using optoelectronic plethysmography. Respiratory Care, 58(8), 1360-1366.

Patil, V., & Desai, M. (2013) Pulmonary function tests. In A.P. Kulkarni, J.V. Divatia, V.P. Patil, & R.P. Gehdoo (Eds.), Objective anaesthesia review:A comprehensive textbook for the examinees (3rd ed.) (p. 345). New Dehli, India: Jaypee Brothers Medical Publishers Ltd.

Restrepo, R., Wettstein, R., Wittnebel, L., & Tracy, M. (2011). AARC clinical practice guideline: Incentive spirometry: 2011. Respiratory Care, 56(10), 1600-1604.

Rollins, K.E., Aggarwal, S., Fletcher, A., Knight, A., Rigg, K., Williams, A.R., & Bhattacharjya, S. (2013). Impact of early incentive spirometry in an enhanced recovery program after laparoscopic donor nephrectomy. Transplantation Proceedings, 45(4), 1351-1353.

Thomas, S., Bausewein, C., Higginson, I., & Booth, S. (2011). Breathlessness in cancer patients--Implications, management and challenges. European Journal of Oncology Nursing, 15(5), 459-469.

Tyson, A.F., Kendig, C.E., Mabedi, C., & Charles, A.G. (2015). The effect of incentive spirometry on postoperative pulmonary function following laparotomy. JAMA Surgery, 150(3), 229-236.

Williams, M.R., Cafarella, P., Paquet, C., & Frith, P. (2015). Cognitive behavioral therapy for management of dyspnea: A pilot study. Respiratory Care, 60(9), 1303-1313.

Yinghong Moore, BSN, RN, CMSRN[R], is RN IV, Staff Nurse, Saint Luke's Hospital of Kansas City, Kansas City, MO.

Emma Shotton, MSN, RN, CMSRN[R], is Assistant Professor, Saint Luke's College of Health Sciences, Kansas City, MO.

Rebecca Brown, MPA, BS, RRT, is Kansas City Regional Coordinator, Asthma Ready Communities, University of Missouri Children's Hospital, Columbia, MO.

Jessica Gremmel, BSTC, RRT-NPS, is Respiratory Care Practitioner III, Saint Luke's Hospital of Kansas City, Kansas City, MO.

Sherrie Lindsey, BSN, RN, CMSRN[R], is Staff Nurse, Saint Luke's Hospital of Kansas City, Kansas City, MO.

Jessica Pankey, BSN, RN, CMSRN[R], is RN IV, Staff Nurse, Saint Luke's Hospital of Kansas City, Kansas City, MO.

Acknowledgments: The authors thank Jacque Carpenter, PhD, RN, and Lisa Riggs, MSN, RN, for their ongoing support and outstanding mentorship with this research. They also thank Jingyan (Grace) Wang, MS, Biostatistician, for the data analysis.

Caption: FIGURE 1. Randomization and Procedure
Mean VAS Values for IS Use and
Placebo at Designated Periods

Treatment   Period    VAS          Mean

              1      Prior    31.3055556
                      Post    31.1388889
Placebo              Change   -0.1666667

              2      Prior    30.1724138
                      Post    29.8275862
                     Change   -0.3448276

              1      Prior    28.7241379
                      Post    33.7586207
IS Use               Change   5.0344828

              2      Prior    29.5555556
                      Post    29.7222222
                     Change   0.1666667

IS = incentive spirometry; VAS = Visual Analog Scale

Mean Max VC Values for IS Use and
Placebo at Designated Periods

Treatment   Period   Max VC      Mean

              1      Prior     1.6491667
                      Post     1.6433333
Placebo              Change   -0.0058333

              2      Prior     1.8293103
                      Post     1.9086207
                     Change   -0.0793103

              1      Prior     1.7275862
                      Post     1.8672414
IS Use               Change    0.1396552

              2      Prior     1.6116667
                      Post     1.6516667
                     Change    0.0400000

IS = incentive spirometry; VC = vital capacity

Mean VAS Values for IS Use and Placebo

Treatment    VAS        Mean

Placebo     Prior    30.8000000
             Post    30.5538462
            Change   -0.2461538

IS Use      Prior    29.1846154
             Post    31.5230769
            Change    2.3384615

IS = incentive spirometry; VAS = Visual Analog Scale

Mean Max VC Values for IS Use and Placebo

Treatment   Max VC     Mean

Placebo     Prior    1.7295385
             Post    1.7616923
            Change   0.0321538

IS Use      Prior    1.6633846
             Post    1.7478462
            Change   0.0844615

IS = incentive spirometry; VC = vital capacity
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Article Details
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Title Annotation:Research for Practice
Author:Moore, Yinghong; Shotton, Emma; Brown, Rebecca; Gremmel, Jessica; Lindsey, Sherrie; Pankey, Jessica
Publication:MedSurg Nursing
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2018
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