By: Jacob Wasserman
Medical education is built upon and grows from knowledge gathered by our predecessors. But when we take the words of those who practiced before us at face value without some level of skepticism, this has the potential to lead to the perpetuation of practices that serve little to no benefit.
While rotating through surgical care, as I watched the team ask each patient on rounds how their incentive spirometry (IS) has been going, I became curious as to how IS was helping the patient. Though it seems almost every post op or ICU note has “encourage IS” as at least part of the pulmonary plan, the literature I have read has expressed minimal support for the practice. These findings made me wonder if there are other commonly followed medical practices that would not stand up to skeptical evaluation.
Take as an example the use of incentive spirometry as a prophylactic measure against pulmonary complications like atelectasis or pneumonia in postoperative patients. Though the general lack of standardized protocol for IS usage mixed with spotty patient compliance makes evaluation challenging, there seems to be no compelling evidence in favor of the practice. Intuitively, from our understanding of respiratory physiology, it may make sense that incentive spirometry can help to open the alveoli and prevent complications. However, the results of multiple systematic reviews, evaluating a total of 59 studies on incentive spirometry effectiveness, do not support IS usage postoperatively1,2,3,4.
In fact, the American Association for Respiratory Care’s clinical guidelines also do not advocate for IS usage to prevent postoperative pulmonary complication5, favoring early mobility and ambulation to promote airway clearance instead. Despite the evidence, IS usage is widely used and done so without standardization.
The continued use of incentive spirometry not only fails to benefit the patient, but also generates negative effects to the healthcare system. One paper analyzing the financial impact of IS use found a per-patient cost of at least $107 and national annual cost of a shocking $949.4 million6. Though this analysis does include the monetary cost of the time nursing and therapy staff dedicate to IS, it does not quantify the negative impact that dedicating that time to IS training has by taking staff away from other tasks.
So why such widespread implementation of IS? I believe this comes from good intentions; providers desire to do something to help and gravitate towards what they have seen others do in the past, without stopping to verify if the practice will indeed generate the intended benefit. Similar analyses and conclusions can be applied to other common practices, such as ordering ammonia levels for suspected hepatic encephalopathy (HE) in a cirrhotic patient (ammonia poorly correlates with HE7, which should be determined through clinical diagnosis), ordering amylase to help diagnose acute pancreatitis (lipase is more specific and sensitive8, but neither correlate well with disease severity or clinical course9), using sequential compression devices (SCDs) as prophylaxis against venous thromboembolism (VTE) on all floor patients (patients generally have poor compliance with SCDs10, SCDs cost roughly $120 per patient11, and VTEs are overall infrequent on the floor so the number-needed-to-treat to prevent one symptomatic VTE with SCDs is 20012; encouraging ambulation instead works well12), or reflexively treating fever with acetaminophen/NSAIDs in patients with known infection (fever positively modulates immune response to infection13; antipyretics have been found to have no benefit on mortality in septic ICU patients14; these medications can adversely affect various organ systems15).
As future physicians, we should work to exercise scientific curiosity and evaluate the evidence behind potential actions in diagnosis, management, and treatment. Doing something just because “that’s how it has been done” is not a justification; don’t let tradition alone guide your practice. I believe physicians have a responsibility to not only know what to do, but also to know why that thing should be done. Keep a healthy dose of skepticism and be willing to challenge convention if that is where knowledge and evidence leads, for the betterment of patient care and the healthcare system overall.
1. Carvalho CR, Paisani DM, Lunardi AC. Incentive spirometry in major surgeries: a systematic review. Brazilian Journal of Physical Therapy. 2011;15(5):343-350. doi:10.1590/s1413-35552011005000025
2. Freitas ERFS, Soares BGO, Cardoso JR, Atallah ÁN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database of Systematic Reviews. 2007. doi:10.1002/14651858.cd004466.pub2
3. Guimarães MMF, El Dib R, Smith AF, Matos D. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews. 2009. doi:10.1002/14651858.cd006058.pub2
4. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C. The Effect of Incentive Spirometry on Postoperative Pulmonary Complications. Chest. 2001;120(3):971-978. doi:10.1378/chest.120.3.971
5. Strickland SL, Rubin BK, Drescher GS, et al. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients. Respiratory Care. 2013;58(12):2187-2193. doi:10.4187/respcare.02925
6. Eltorai AEM, Baird GL, Pangborn J, et al. Financial Impact of Incentive Spirometry. Inquiry. 2018;55:46958018794993. doi:10.1177/0046958018794993
7. Ong JP, Aggarwal A, Krieger D, et al. Correlation between ammonia levels and the severity of hepatic encephalopathy. Am J Med. 2003;114(3):188-193. doi:10.1016/s0002-9343(02)01477-8
8. Smith RC, Southwell-Keely J, Chesher D. Should serum pancreatic lipase replace serum amylase as a biomarker of acute pancreatitis? ANZ J Surg. 2005;75(6):399–404.
9. Banks PA, Freeman ML, Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101(10):2379–2400.
10. Cornwell EE III, Chang D, Velmahos G, et al. Compliance with sequential compression device prophylaxis in at-risk trauma patients: a prospective analysis. Am Surg. 2002;68(5):470-473.
11. Casele H, Grobman WA. Cost-effectiveness of thromboprophylaxis with intermittent pneumatic compression at cesarean delivery. Obstet Gynecol. 2006;108(3 Pt 1):535-540. doi:10.1097/01.AOG.0000227780.76353.05
12. Jenkins IH, White RH, Amin AN, et al. Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: Findings from five University of California medical centers. J Hosp Med. 2016;11 Suppl 2:S22-S28. doi:10.1002/jhm.2658
13. Hasday JD, Fairchild KD, Shanholtz C. The role of fever in the infected host. Microbes and Infection. 2000;2(15):1891-1904. doi:10.1016/s1286-4579(00)01337-x
14. Drewry AM, Ablordeppey EA, Murray ET, et al. Antipyretic Therapy in Critically Ill Septic Patients. Critical Care Medicine. 2017;45(5):806-813. doi:10.1097/ccm.0000000000002285
15. Greisman LA, Mackowiak PA. Fever: beneficial and detrimental effects of antipyretics. Current Opinion in Infectious Diseases. 2002;15(3):241-245. doi:10.1097/00001432-200206000-00005