INCENTIVE SPIROMETRY 1.1.

Definition: Incentive spirometry, also known as Sustained Maximal Inspiration (SMI), is a technique used to encourage a patient to take a maximal inspiration using a device to measure flow or volume. A maximal inspiration sustained over three seconds may increase the transpulmonary pressure thereby improving inspiratory volumes and inspiratory muscle performance. With repetition, and as part of an overall bronchial hygiene program, SMI maneuvers may reverse lung atelectasis and restore and maintain airway patency. The device used to facilitate SMI, the incentive spirometer, incorporates visual indicators of performance in order to aid the therapist in coaching the patient to optimal performance. Likewise, patients may use this visual feedback to monitor their own efforts. 1.2. Indications 1.2.1 Conditions predisposing a patient to the development of atelectasis such as upperabdominal or thoracic surgery, prolonged bed rest, surgery in patients with chronic obstructive pulmonary disease, a lack of pain control, or the presence of thoracic or abdominal binders. 1.2.2 The presence of pulmonary atelectasis. 1.2.3 Presence of a restrictive lung defect associated with a dysfunctional diaphragm or involving the respiratory musculature. 1.2.4 Preoperative screening of patients at risk for pulmonary complications postoperatively: a baseline flow or volume may be obtained to aid in assessing the patients postoperative function. 1.3 Contraindications 1.3.1 The patient cannot be instructed to ensure proper use of the device, or patient cooperation is absent or hindered. Developmental age may preclude the use of this technique in very young patients and others with developmental delays. A patient must be able to take a deep breath through the mouth only while maintaining a tight seal on the mouthpiece. Pediatric incentive spirometers should be used in the preadolescent age groups to encourage motivation and facilitate instruction. Additionally, instruction of parents, guardians, and other health care givers in the technique of incentive spirometry may help to facilitate the childs appropriate use of the technique. 1.3.2 The patient is unable to take a deep breath; the patients vital capacity should be at least 10 mL/kg. 1.4 Precautions 1.4.1 The technique is inappropriate as the sole treatment for major lung collapse or consolidation. 1.4.2 Hyperventilation may result from improper technique. 1.4.3 There is potential for barotrauma in emphysematous lungs. 1.4.4 Discomfort may occur secondary to uncontrolled pain. 1.4.5 Development of bronchospasm may occur in susceptible patients. Close monitoring of patients with hyperreactive airways should be maintained.

2.0 EQUIPMENT 2.1 Incentive spirometer appropriate to age of patient (pediatric or adult) 2.2 Adapters if needed (e.g., for use with a tracheostomized patient) 3.0 PROCEDURE 3.1 Introduce oneself to the patient and assess the appropriateness of the therapy for the patient 3.2 Describe the proper technique as well as the importance of adequate therapy for optimal bronchial hygiene. NOTE: A maximal inspiration should be sustained for a minimum of three seconds. 3.3 Perform a pre- and post-treatment assessment of breathing pattern, frequency, and lung sounds. 3.4 Position the patient for optimal therapy (as erect as possible without causing the patients level of pain to increase). 3.5 Assist the patient while he/she performs 10 maneuvers. Encourage the patient to perform the technique independently with five to ten breaths per session every hour while awake. 3.6 Encourage the patient to cough during and after the session using optimal technique and effort. 4.0 POST PROCEDURE: Direct supervision and therapist interaction may be decreased after the patient has demonstrated proper performance of the task and if motivation is sufficient. 4.1 Supervision and monitoring should be performed intermittently (at least once daily) to include: 4.1.1 Number of attempts per session 4.1.2 Inspiratory volume achieved 4.1.3 Effort/motivation and compliance 4.2 An assessment of outcome should also be made. A positive outcome of incentive spirometry and criteria for discontinuance: 4.2.1 Absence or resolution of atelectasis as shown by any of the following: 4.2.1.1 A decreased respiratory rate 4.2.1.2 The absence of fever 4.2.1.3 Absence or abolition of crackles and improved aeration of lung units

4.2.1.4 Improving chest radiograph 4.2.1.5 Attainment of preoperative flow and volume levels 4.2.1.6 Increased forced vital capacity

Pulse Oximetry Description

Provides an estimate of arterial oxyhemoglobin saturation by using selected wavelengths of light to noninvasively determine the saturation of oxyhemoglobin. Oximeters function by passing a light beam through a vascular bed, such as the finger or earlobe, to determine the amount of light absorbed by oxygenated (red) and deoxygenated (blue) blood. Calculates the amount of arterial blood that is saturated with oxygen (Sao2) and displays this as a digital value.

Indications include: Monitor adequacy of oxygen saturation; quantify response to therapy. Monitor unstable patient who may experience sudden changes in blood oxygen level. o Evaluation of need for home oxygen therapy. o Determine supplemental oxygen needs at rest, with exercise, and during sleep. o Need to follow the trend and need to decrease number of ABG sample drawn. The oxyhemoglobin dissociation curve allows for correlation between Sao2 and PaO2 o Increased body temperature, acidosis, and increased 2,3- DPG cause a shift in the curve to the right, thus increasing the ability of hemoglobin to release oxygen to the tissues. o Decreased temperature, decreased 2,3-DPG, and alkalosis cause a shift to the left, causing hemoglobin to hold on to the oxygen, reducing the amount of oxygen being released to the tissues. Increased bilirubin, increased carboxyhemoglobin, low perfusion or Sao2 < 80% may alter light absorption and interfere with results
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NURSING ALERT There is a potential error in Sao2 readings of 2% that can increase to greater than 2% if the patient's SpO2 drops below 80%. Oximeters rely on differences in light absorption to determine Sao2. At lower saturations, oxygenated hemoglobin appears bluer in color and is less easily distinguished from deoxygenated hemoglobin. ABG analysis should be used in this situation. Nursing and Patient Care Considerations

Assess patient's hemoglobin. Sao2 may not correlate well with PaO2 if hemoglobin is not within normal limits. Remove patient's nail polish because it can affect the ability of the sensor to correctly determine oxygen saturation, particularly polish with blue or dark colors.

Correlate oximetry with ABG values and then use for single reading or trending of oxygenation (does not monitor Paco2). Display heart rate should correlate with patient's heart rate. To improve quality of signal, hold finger dependent and motionless (motion may alter results) and cover finger sensor to occlude ambient light. Assess site of oximetry monitoring for perfusion on a regular basis, because pressure ulcer may occur from prolonged application of probe. Device limitations include motion artifact, abnormal hemoglobins (carboxyhemoglobin and methemoglobin), I.V. dye, exposure of probe to ambient light, low perfusion states, skin pigmentation, nail polish or nail coverings, and nail deformities such as severe clubbing. Document inspired oxygen or supplemental oxygen and type of oxygen delivery device. Accuracy can be affected by ambient light, I.V. dyes, nail polish, deeply pigmented skin, patients in sickle cell crisis, jaundice, severe anemia, and use of antibiotics such as sulfas.