Incentive Spirometry and Chest Physiotherapy Guidance

Incentive Spirometry: Definition and Physiological Mechanism

• The incentive spirometer (Figure $7.12$) is a handheld respiratory device engineered to support patients in deep-breathing exercises.

• The primary goal of the device is to encourage the patient to breathe slowly and deeply to facilitate lung expansion.

• Clinical Purpose: The device is used to prevent or reverse atelectasis (collapse of the lung tissue).

• Physiological Action: When a patient takes a slow, deep breath and holds it, the alveoli expand. This expansion reduces the risk of alveolar collapse and improves the patient's oxygenation.

• Visual Components of Figure $7.12$:

  • The device includes a volume scale ranging from $500$ to $4000$.

  • It features a designated "KEEP INDICATOR BETWEEN ARROWS" guide to ensure the appropriate inspiratory flow rate.

Indications for Use and Clinical Significance

• Healthcare providers prescribe the incentive spirometer for several patient populations, including:

  • Patients who have undergone a surgical procedure.

  • Patients diagnosed with chronic breathing problems or other pulmonary issues.

  • Patients on ordered bedrest.

  • Patients with extended hospital stays associated with decreased or limited mobility.

• Therapeutic Rationale: Limited mobility increases the possibility of developing atelectasis, which subsequently increases the secondary risk for pneumonia.

Nursing Implications and Patient Teaching for Incentive Spirometry

• Usage Frequency: Nurses should encourage the patient to use the device approximately $5$ to $10$ times per hour during waking hours.

• Goal Setting: Incentive spirometry goals are established based on the individual performance of the patient.

• Preoperative Teaching: For surgical patients, it is best to complete teaching and goal-setting preoperatively. This is because postoperative factors such as pain or sedation can significantly impair the patient's respiratory effort.

• Expected Outcomes: Repeated use of the device can improve lung expansion and assist in the mobilization and removal of secretions from the respiratory airways (Box $7.2$).

• Bedside Accessibility: The device must be kept at the bedside within the patient's reach to promote compliance.

• Documentation: Nurses must document the exercises and their effectiveness in the patient's healthcare record.

Step-by-Step Procedure for Incentive Spirometer Use (Box $7.2$)

• Step $1$: Explain the correct use and physiological indication for incentive spirometry to the patient.

• Step $2$: Assist the patient into a sitting position, specifically semi-Fowler’s, provided there are no contraindications. This position allows for optimal lung expansion.

• Step $3$: Instruct the patient to exhale completely.

• Step $4$: Instruct the patient to place the mouthpiece in their mouth and form a tight seal with their lips. A good seal is required for the device to function effectively.

• Step $5$: Instruct the patient to take a slow, smooth, deep breath, resembling the action of inhaling through a straw.

• Step $6$: Once the patient achieves maximal inspiration and cannot inhale further, they should hold their breath for approximately $3\,s$.

• Step $7$: Direct the patient to exhale smoothly and slowly to maintain alveolar expansion.

• Step $8$: Encourage a rest period of a few seconds between individual exercises.

• Step $9$: Instruct the patient to cough after each session to facilitate airway clearance of mobilized secretions.

Chest Physiotherapy (CPT): Overview and Goals

• Chest physiotherapy is ordered when a patient requires physical assistance in removing pulmonary secretions.

• Components of CPT: It consists of a combination of percussion, vibration, and postural drainage.

• Primary Objective: The goal is to move secretions from peripheral areas into the main airways, allowing for an effective cough and improved ventilation.

• Scheduling and Preparation:

  • CPT is typically ordered $1\,h$ before meals or $3\,h$ after meals to prevent discomfort or aspiration.

  • A bronchodilator may be administered before the procedure to facilitate bronchial dilation and improve secretion removal.

• Post-Procedure Actions:

  • Patients are encouraged to breathe deeply and cough after treatment.

  • If the patient cannot produce an effective independent cough, suctioning may be required to clear the airway.

Postural Drainage: Methodology and Patient Positioning

• Definition: Postural drainage uses the force of gravity to assist in moving pulmonary secretions from smaller segments of the lungs toward the trachea.

• Mechanism: When the head is positioned lower than the chest, secretions drain toward the trachea, where they can be expectorated or suctioned.

• Clinical Tools: Practioners may use pillows, positional hospital beds, or tilt tables to achieve necessary angles.

• Duration: Each specified position should be held for $3$ to $15\,min$, or longer if specifically ordered.

• Medical Pre-treatment: Bronchodilators and mucolytic medications may be utilized beforehand to improve the efficiency of secretion removal.

• Modifications and Contraindications:

  • Positions are modified based on the patient's physical condition or tolerance.

  • Patients with chronic respiratory or cardiac conditions (e.g., COPD or heart failure) may be unable to tolerate the head-down position.

• Specific Anatomical Targets (Figure $7.13$):

  • Right and Left anterior segments.

  • Right middle lobe.

  • Right posterior segments.

  • Left lingular.

  • Anterior segments of the lower lobes.

  • Left lateral segment.

Manual Techniques: Percussion and Vibration

• Chest Percussion Technique (Figure $7.14$):

  • Performed by lightly striking the chest wall over the target lung segment.

  • Hands must be cupped with fingers and thumbs closed.

  • The nurse alternates cupped hands to facilitate secretion movement into larger airways.

  • Safety: Percussion must be performed over a gown or thin clothing to protect the skin; it must never be performed over buttons, snaps, or zippers.

  • Administration: Can be performed manually or with a mechanical device if ordered by a provider only on the specific area indicated.

• Vibration Technique:

  • Performed with the hands in a flat position.

  • The hand moves repeatedly to cause vibration over the target lung segment.

  • Timing: Manual vibration is performed specifically during exhalation to loosen secretions and induce coughing.

Alternative Airway Clearance Devices

• Acapella Device:

  • A handheld device that mobilizes secretions using positive expiratory pressure and airway vibration.

  • It can be used in any setting and is often easier for patients to tolerate than traditional CPT.

• High-Frequency Chest Wall Compression (HFCWC) Device:

  • An air-filled, vibrating vest that applies a continuous, gentle vibrating motion to the chest.

  • Assists in the removal of pulmonary secretions and is suitable for home use following hospital discharge.

• Patient Education: With appropriate teaching, both the patient and their caregivers can use these devices independently without clinical assistance.