Name (xxxxxxx) Systematic Literature Review Final version
The effect of volume-incentive spirometry in comparison
to flow incentive spirometry on pulmonary function in
adult patients after cardiothoracic or abdominal surgery:
A systematized review
Student: xxxxx
Student ID: xxxxx
Course: Systematic Literature Review
Study: Master Clinical Health Sciences, Nursing Science
Status: Final version
Date: April 10, 2024
Word count abstract: 300
Word count manuscript: 3268
Lecturer: xxxxx
University Utrecht, the Netherlands
1
,Name (xxxxxxx) Systematic Literature Review Final version
Abstract
Background: Postoperative pulmonary complications (PPCs), including atelectasis and
respiratory infections, could result in risks following cardiothoracic and upper abdominal
surgeries, affecting morbidity and mortality rates. Incentive Spirometry (IS) is commonly used
in clinical practice aimed to reduce these risks. However, controversies persist regarding its
clinical effectiveness, particularly regarding the comparative efficacy of flow incentive
spirometry and volume-incentive spirometry.
Aim: This review aimed to compare the effects of volume incentive spirometry versus flow
incentive spirometry on pulmonary function for adult patients following cardiac, or abdominal
surgery.
Methods: A systematized approach was conducted by one researcher. PubMed, Embase and
Cinahl were used as data sources. A comprehensive search was conducted to identify eligible
studies. Studies were included if they examined adult patients following cardiac or
(laparoscopic) abdominal surgery and compared the effects of volume spirometry versus flow
spirometry on forced vital capacity. One researcher conducted screening and data-extraction,
while two reviewers independently assessed methodological quality using the JBI framework.
Results: Six articles were included (five RCTs, one pilot RCT) involving 277 adults undergoing
cardiac or abdominal surgery. Two low and moderate quality articles regarding cardiac and
abdominal surgery showed significant higher FVC values in the VS group in comparison to the
FS group. The other three studies, ranging from low to moderate quality, did not find significant
differences between the FS and VS groups in mean FVC values.
Conclusion: The review findings suggest limited and inconsistent evidence regarding the
effectiveness of spirometry devices in pulmonary function following cardiac and abdominal
surgery.
Implication of key findings: Due to the overall inconsistency and low-quality nature of the
studies suggest that there is no preference for either spirometry devices in terms of FVC
values. Further randomized controlled clinical trials, with a larger sample size, should be
conducted to gain robust results with high evidence.
Keywords
Cardiac surgery; upper abdominal surgery; incentive spirometry; pulmonary function;
pulmonary complications
2
, Name (xxxxxxx) Systematic Literature Review Final version
Introduction
Worldwide, it is estimated that more than 230 million major surgical procedures are conducted
annually1. Predominantly, cardiothoracic, and upper abdominal surgeries constitute the most
prevalent among these procedures. Following these surgeries, patients have a decreased
pulmonary function2–4. Moreover, patients are at risk experiencing adverse events known as
postoperative pulmonary complications (PPCs)5,6. These complications are broadly defined as
atelectasis, pleural effusion, respiratory failure, respiratory infection, pneumothorax,
bronchospasm, or aspiration pneumonitis. Such complications are the leading cause of
mortality, morbidity, and increased health care costs7,8. After cardiothoracic and abdominal
surgeries, there is a reported incidence of PPCs of 5% up to 90%7,8. The wide variation in
incidence of PPCs may be attributed to the lack of consensus to which conditions constitute
PPCs8.
Multifactorial components may influence the respiratory system, thereby decreasing the
pulmonary function and increasing the risk of developing PPCs. For example, extracorporeal
circulation, duration of surgery, and duration of mechanical ventilation8,9. Moreover,
postoperative pain leads to shallow breathing, which further reduces functional residual
capacity and inspiratory volumes, potentially causing atelectasis and pneumonia8,10. Impaired
movement of the diaphragm and chest wall in addition to reduced pulmonary compliance
during anesthesia also hinders inspiratory volume, which increases the risk of PPCs8.
Therefore, effective interventions, particularly by nurses, are crucial for preventing PPCs11,12.
For instance, accurate pain management and early mobilization have been acknowledged as
effective and preventive interventions following cardiothoracic and abdominal surgery11,13–15.
Additionally, Incentive Spirometry (IS) is commonly used in clinical practice as an intervention
aimed at enhancing pulmonary function and reducing PPCs in patients undergoing
cardiothoracic or abdominal surgery16. The spirometry involves patients performing prolonged,
deliberate deep inhalations using mechanical devices, with visual feedback. IS comes in two
types: flow incentive spirometry (FS) and volume-incentive spirometry (VS) (Appendix A). The
FS consists of a mouthpiece, flexible tubing, and three flow tubes with plastic balls ascending
based on inhalation intensity. The VS aids inhalation via a mouthpiece and corrugated tubing
connected to a bellows, with air volume indicated on a scale17. Studies comparing the two
devices suggest differences in physiological effects: FS increases upper chest muscle activity,
while VS enhances diaphragmatic activity18.
Researchers suggests that VS promotes a greater chest wall volume with a larger abdominal
contribution than does FS which could possible lead to different clinical outcomes19,20. Since
3
The effect of volume-incentive spirometry in comparison
to flow incentive spirometry on pulmonary function in
adult patients after cardiothoracic or abdominal surgery:
A systematized review
Student: xxxxx
Student ID: xxxxx
Course: Systematic Literature Review
Study: Master Clinical Health Sciences, Nursing Science
Status: Final version
Date: April 10, 2024
Word count abstract: 300
Word count manuscript: 3268
Lecturer: xxxxx
University Utrecht, the Netherlands
1
,Name (xxxxxxx) Systematic Literature Review Final version
Abstract
Background: Postoperative pulmonary complications (PPCs), including atelectasis and
respiratory infections, could result in risks following cardiothoracic and upper abdominal
surgeries, affecting morbidity and mortality rates. Incentive Spirometry (IS) is commonly used
in clinical practice aimed to reduce these risks. However, controversies persist regarding its
clinical effectiveness, particularly regarding the comparative efficacy of flow incentive
spirometry and volume-incentive spirometry.
Aim: This review aimed to compare the effects of volume incentive spirometry versus flow
incentive spirometry on pulmonary function for adult patients following cardiac, or abdominal
surgery.
Methods: A systematized approach was conducted by one researcher. PubMed, Embase and
Cinahl were used as data sources. A comprehensive search was conducted to identify eligible
studies. Studies were included if they examined adult patients following cardiac or
(laparoscopic) abdominal surgery and compared the effects of volume spirometry versus flow
spirometry on forced vital capacity. One researcher conducted screening and data-extraction,
while two reviewers independently assessed methodological quality using the JBI framework.
Results: Six articles were included (five RCTs, one pilot RCT) involving 277 adults undergoing
cardiac or abdominal surgery. Two low and moderate quality articles regarding cardiac and
abdominal surgery showed significant higher FVC values in the VS group in comparison to the
FS group. The other three studies, ranging from low to moderate quality, did not find significant
differences between the FS and VS groups in mean FVC values.
Conclusion: The review findings suggest limited and inconsistent evidence regarding the
effectiveness of spirometry devices in pulmonary function following cardiac and abdominal
surgery.
Implication of key findings: Due to the overall inconsistency and low-quality nature of the
studies suggest that there is no preference for either spirometry devices in terms of FVC
values. Further randomized controlled clinical trials, with a larger sample size, should be
conducted to gain robust results with high evidence.
Keywords
Cardiac surgery; upper abdominal surgery; incentive spirometry; pulmonary function;
pulmonary complications
2
, Name (xxxxxxx) Systematic Literature Review Final version
Introduction
Worldwide, it is estimated that more than 230 million major surgical procedures are conducted
annually1. Predominantly, cardiothoracic, and upper abdominal surgeries constitute the most
prevalent among these procedures. Following these surgeries, patients have a decreased
pulmonary function2–4. Moreover, patients are at risk experiencing adverse events known as
postoperative pulmonary complications (PPCs)5,6. These complications are broadly defined as
atelectasis, pleural effusion, respiratory failure, respiratory infection, pneumothorax,
bronchospasm, or aspiration pneumonitis. Such complications are the leading cause of
mortality, morbidity, and increased health care costs7,8. After cardiothoracic and abdominal
surgeries, there is a reported incidence of PPCs of 5% up to 90%7,8. The wide variation in
incidence of PPCs may be attributed to the lack of consensus to which conditions constitute
PPCs8.
Multifactorial components may influence the respiratory system, thereby decreasing the
pulmonary function and increasing the risk of developing PPCs. For example, extracorporeal
circulation, duration of surgery, and duration of mechanical ventilation8,9. Moreover,
postoperative pain leads to shallow breathing, which further reduces functional residual
capacity and inspiratory volumes, potentially causing atelectasis and pneumonia8,10. Impaired
movement of the diaphragm and chest wall in addition to reduced pulmonary compliance
during anesthesia also hinders inspiratory volume, which increases the risk of PPCs8.
Therefore, effective interventions, particularly by nurses, are crucial for preventing PPCs11,12.
For instance, accurate pain management and early mobilization have been acknowledged as
effective and preventive interventions following cardiothoracic and abdominal surgery11,13–15.
Additionally, Incentive Spirometry (IS) is commonly used in clinical practice as an intervention
aimed at enhancing pulmonary function and reducing PPCs in patients undergoing
cardiothoracic or abdominal surgery16. The spirometry involves patients performing prolonged,
deliberate deep inhalations using mechanical devices, with visual feedback. IS comes in two
types: flow incentive spirometry (FS) and volume-incentive spirometry (VS) (Appendix A). The
FS consists of a mouthpiece, flexible tubing, and three flow tubes with plastic balls ascending
based on inhalation intensity. The VS aids inhalation via a mouthpiece and corrugated tubing
connected to a bellows, with air volume indicated on a scale17. Studies comparing the two
devices suggest differences in physiological effects: FS increases upper chest muscle activity,
while VS enhances diaphragmatic activity18.
Researchers suggests that VS promotes a greater chest wall volume with a larger abdominal
contribution than does FS which could possible lead to different clinical outcomes19,20. Since
3
