Review Question - QID 106160

The patient in this vignette would be likely to prevent postoperative pneumonia by the use of incentive spirometry and deep breathing exercises.

Postoperative pneumonia is defined as hospital-acquired or ventilator-associated pneumonia in a postsurgical patient. Atelectasis is a very common complication after surgery, and it occurs when a patient is unable to breathe in enough air to fill their lungs completely. Post-operative pain is one of the primary causes of this, and the resultant atelectasis leads to mucous trapping and pneumonia. Incentive spirometry and deep breathing exercises help to prevent mucous build-up and alveolar collapse in the lungs. Moreover, adequate pain control and early mobilization are additional modalities used to help prevent lower lobe atelectasis. An incentive spirometer is a handheld device with a flexible plastic tube that is connected to an air column and piston, which ultimately measures how much air one is able to breathe in.

King discusses the use of incentive spirometry in the preoperative and postoperative patient. Even though all pulmonary infections should be treated preoperatively, prevention of pulmonary complications should always start with instructing patients on deep breathing exercises and incentive spirometry use. Both deep breathing exercises and incentive spirometry use have been shown to be particularly effective in the postoperative patient who is obese, has lung disease, or has undergone thoracic or abdominal procedures.

Thomas et al. report on the use of incentive spirometry in the postoperative patient. They performed a meta-analysis which included 14 citations based on relevance criteria requirements. They found that incentive spirometry use appeared to be more effective than no physical therapy intervention in the prevention of postoperative pulmonary complications. However, they were unable to determine a significant difference between the three prophylactic modalities: incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises.

Illustration A depicts a clinical photograph of an incentive spirometer that is often used in the postoperative patient. Illustration B demonstrates a chest radiograph taken on postoperative day 5 and read as worsening left lower lobe atelectasis. Illustration C is a chest radiograph showing a very prominent wedge-shape area of airspace consolidation in the right lung characteristic of bacterial pneumonia. Video V demonstrates the function and use of an incentive spirometer.

Incorrect Answers:
Answer 1: In-hospital intravenous antibiotics used for pneumonia treatment are commonly seen in individuals >65 years old with multi-lobar pneumonia, in patients with significant comorbidities including alcoholism, COPD, malnutrition, diabetes, immunocompromised, altered mental status or in those individuals in respiratory failure.
Answer 2: Outpatient oral antibiotics are used in cases of known/diagnosed uncomplicated pneumonia. In these cases, medications are directed at the sensitivity of the known pathogens and/or additional broad coverage.
Answer 3: Hyperbaric oxygenation has not been shown to be beneficial in preventing postoperative pneumonia.
Answer 5: Shallow breathing exercises are not used clinically to prevent atelectasis and resultant pneumonia. On the contrary, deep breathing exercises (in addition to incentive spirometry) have been shown to reduce atelectasis and help prevent postoperative pneumonia.