Physiotherapy Treatment Plan

CLINICAL REASONING

• Lactic acidosis indicates tissue hypoperfusion or metabolic dysregulation - physiotherapy must not increase oxygen demand beyond what the patient can tolerate
• Non-cardiogenic pulmonary edema (NCPE) - alveolar flooding from increased capillary permeability (ARDS spectrum), not elevated cardiac filling pressures; diuretics/vasodilators have limited role, ventilatory support and lung-protective strategies are key
• LRTI - likely the precipitating cause; produces retained secretions, V/Q mismatch, and consolidation requiring active airway clearance

PRE-TREATMENT ASSESSMENT

Baseline Parameters (Assess Before Each Session)

Contraindications / Precautions for This Patient

• Unstable lactic acidosis (pH < 7.25, rising lactate > 4 mmol/L) - defer active exercise, focus on positioning only
• Severe hypoxemia (SpO2 < 88% at rest on nasal cannula) - do not proceed with airway clearance techniques without MDT discussion
• Hemodynamic instability - systolic BP < 90 mmHg, HR < 40 or > 130/min: defer session
• Active bronchospasm - contra-indication to percussion
• Thrombocytopenia - use vibration instead of percussion if platelets < 50,000

PHYSIOTHERAPY GOALS

TREATMENT PLAN - PHASE 1 (Days 5-7): ACUTE PHASE

1. Positioning and Postural Management

• Head of bed elevation 30-45° at all times - reduces pulmonary congestion, improves functional residual capacity (FRC), and reduces aspiration risk in LRTI
• High side-lying positions (alternating left and right) - recruits non-dependent lung zones affected by edema pooling
• Prone positioning - strongly consider if SpO2 remains borderline (88-91%) on nasal cannula; supported by evidence in ARDS-spectrum disease for improving oxygenation through better V/Q redistribution. Coordinate with nursing team for 4-hour prone periods if tolerated
• Avoid supine flat position - worsens dyspnea, increases WOB, and promotes edema distribution to posterior lung zones
• Frequency: Position change every 2 hours

2. Active Cycle of Breathing Techniques (ACBT)

1. Breathing Control (BC): Relaxed diaphragmatic breathing at the patient's own rate and depth. Interspersed between active components to prevent fatigue and bronchospasm. Duration: 30-60 seconds per cycle.
2. Thoracic Expansion Exercises (TEE): 3-4 deep breaths, with a 3-second hold at end-inspiration (inspiratory hold promotes collateral ventilation via pores of Kohn and channels of Lambert, helping air to get behind mucus). Can be combined with manual chest compression on expiration.
3. Forced Expiration Technique (FET) / Huff Coughing: One or two huffs (forced expiration from mid-to-low lung volume with an open glottis) followed by breathing control. Huff is less tiring and less likely to cause dynamic airway collapse compared to explosive coughing.

3. Breathing Retraining

• Inhale slowly through the nose for 2 counts, exhale through pursed lips for 4 counts
• Slows respiratory rate, increases tidal volume, prevents dynamic airway collapse, and reduces the oxygen cost of breathing
• Particularly useful during activities, position changes, and any exertional dyspnea
• Evidence: PLB has been shown to reduce hypoxemia and decrease dyspnea in patients with obstructive and restrictive respiratory disease (Murray & Nadel's Textbook of Respiratory Medicine)

• Place one hand on chest, one on abdomen; breathe so the abdomen rises preferentially
• Consciously coordinate abdominal wall expansion with inspiration
• Reduces accessory muscle use, lowers RR, increases tidal volume
• Evidence: Diaphragmatic breathing exercises significantly reduced dyspnea scores and fatigue in hospitalized respiratory patients and improved NYHA functional classification (Nasirmoghadas et al., 2025, BMC Cardiovascular Disorders, PMID: 39794689, RCT)

4. Manual Chest Physiotherapy

• Percussion (Clapping): Rhythmic manual force applied over lung segments for 1-2 minutes per affected zone. Use padded hand/cupped technique. Loosens adherent secretions by mechanical energy transfer.
• Vibrations: Applied during expiration phase (chest vibration or shaking). Increases peak expiratory flow, promoting mucus movement toward central airways. Safer alternative if percussion is contraindicated.
• Postural Drainage: Place patient in positions that use gravity to drain the affected segment. In NCPE, avoid aggressive head-down positions as they may worsen dyspnea - use modified positions (semi-reclined side-lying).

5. Incentive Spirometry

• Set initial target: 70-80% of predicted inspiratory capacity or at patient's comfortable maximum
• 10 repetitions per hour while awake, with rest between efforts
• Evidence: Early pulmonary rehabilitation with incentive spirometry in acute exacerbations significantly improved pulmonary function and reduced complications vs. standard care (Andrea Ban et al., 2024, Med J Malaysia, PMID: 39352158, RCT)

6. Secretion Clearance - Adjuncts (if Available)

• Flutter VRP1 / Oscillating PEP device: Patient exhales through the device, which creates oscillating positive expiratory pressure + airflow oscillations - both mechanically loosens mucus and improves expiratory flow
• High Frequency Chest Wall Oscillation (HFCWO): If available, consider for Day 7+ if secretion burden persists
• Manual Assisted Cough: If cough is weak, the therapist applies abdominal thrust during expiratory phase to augment peak cough flow

TREATMENT PLAN - PHASE 2 (Days 7-10): PROGRESSIVE MOBILIZATION

7. Early Mobilization Protocol

• Continuous SpO2 monitoring - suspend if SpO2 < 88% for > 30 seconds
• Borg dyspnea and exertion scale should not exceed 5/10
• Titrate nasal cannula flow rate upward during exercise if required
• Stop immediately: chest pain, palpitations, pallor, confusion, SpO2 < 85%

8. Upper and Lower Limb Strengthening

• Lower limbs: Ankle dorsiflexion/plantarflexion, straight leg raises, knee extension - performed in supine/sitting to prevent peripheral muscle wasting
• Upper limbs: Shoulder flexion/abduction, elbow flexion/extension, grip exercises with a soft ball
• Frequency: Once daily, 10-15 minutes
• Rationale: Peripheral muscle weakness is a major driver of exercise limitation in respiratory patients. Maintaining limb strength reduces the deconditioning spiral.

TREATMENT PLAN - PHASE 3 (Days 10+): PRE-DISCHARGE & EDUCATION

9. Functional Exercise Training

• Supervised walking program: begin with 10-metre corridor walks, progressing to 50-100 metres with rest stops
• Stair climbing if discharge environment requires it (practice with physiotherapist present)
• 6-Minute Walk Test (6MWT) as discharge readiness marker when stable

10. Patient and Carer Education

11. Discharge Planning

• Refer to outpatient pulmonary rehabilitation program post-discharge
• Home-based exercise diary (steps per day, Borg scale tracking)
• Spirometry and 6MWT at 2-week and 6-week follow-up
• Physiotherapy discharge summary to GP with objective findings and home plan

PRECAUTIONS SPECIFIC TO THIS PATIENT'S DIAGNOSES

Lactic Acidosis Precautions

• Lactic acidosis resolves when the underlying cause is treated and tissue perfusion is restored (Washington Manual of Medical Therapeutics). Physiotherapy must not increase systemic oxygen demand when it cannot be met.
• Daily review of serum lactate with medical team before planning exercise intensity
• Any physiotherapy-induced increase in WOB must be compensated by increased nasal cannula O2 flow

Non-Cardiogenic Pulmonary Edema Precautions

• Unlike cardiogenic pulmonary edema, NCPE does not respond to diuretics in the same way and does not benefit from positional fluid redistribution strategies used in heart failure
• Avoid aggressive fluid administration (not a physiotherapy role but relevant to positioning in context of edema)
• Prone positioning and lung recruitment strategies (via breathing exercises) are the mainstays of physiotherapy management in NCPE/ARDS spectrum (Barash Clinical Anesthesia, 9e)

LRTI Precautions

• Use appropriate PPE (mask, gloves) when managing productive cough
• Ensure patient has tissue or sputum pot for expectoration
• Track sputum colour and volume - purulent increase warrants medical review
• Bronchospasm during ACBT/percussion: stop session, allow patient to use prescribed bronchodilator, resume with gentler techniques

OUTCOME MEASURES

SESSION SUMMARY TABLE

REFERENCES

1. Fishman's Pulmonary Diseases and Disorders (2-Volume Set) - Respiratory and Chest Physiotherapy Techniques; Breathing Retraining Techniques; Bronchial Hygiene; Exercise Prescription (Chapters on Pulmonary Rehabilitation)
2. Murray & Nadel's Textbook of Respiratory Medicine - Inspiratory Muscle Training, Breathing Training and Chest Physical Therapy - Section on pursed-lip breathing, hypoxemia reduction, and oxygen cost of breathing
3. Washington Manual of Medical Therapeutics - Lactic Acidosis: Treatment - "Lactic acidosis will resolve once the underlying cause is treated and tissue perfusion is restored"
4. Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e - Distribution of Ventilation - Non-cardiogenic pulmonary edema mechanism (increased capillary permeability causing V/Q mismatch and impaired diffusion)
5. Pecorelli N, Eggmann S, Jeitziner MM, et al. Early Rehabilitation Interventions and Physical Therapy in Adults Who Were Critically Ill With COVID-19 Pneumonia. Phys Ther. 2023 Feb;103(2):pzac157. PMID: 37104624 - Early PT within 72 hours is safe and feasible in critically ill respiratory patients; median time to edge-of-bed mobilization < 4 days.
6. Nasirmoghadas A, Monjazebi F, Nasiri M, et al. Comparison of diaphragmatic breathing exercises and incentive spirometry on the functional status of heart failure patients: a randomized controlled trial. BMC Cardiovasc Disord. 2025;25(1). PMID: 39794689 - Both diaphragmatic breathing and incentive spirometry significantly reduced dyspnea, fatigue, and improved functional class in hospitalized cardiorespiratory patients (RCT, n=90).
7. Andrea Ban YL, Siti Istiana AS, Nik Nuratiqah NA, et al. The benefits of early pulmonary rehabilitation with incentive spirometer among COPD patients with exacerbation. Med J Malaysia. 2024 Sep. PMID: 39352158 - Early pulmonary rehab with incentive spirometry improved pulmonary function in hospitalized acute exacerbation (RCT).
8. Huang C, Zhao X, Geng S, et al. Non-drug perioperative interventions to reduce postoperative pulmonary complications after abdominal surgery: systematic review and meta-analysis. BMJ. 2026 Apr. PMID: 41956522 - Breathing exercises and early mobilization reduce pulmonary complications in hospitalized patients (Systematic Review/Meta-Analysis).

Spirometer - Complete Guide

What is a Spirometer?

1. Diagnostic spirometry - a pulmonary function test measuring airflow and lung volumes to diagnose and classify respiratory disease
2. Incentive spirometry - a therapeutic device used to encourage deep inspiratory effort, prevent atelectasis, and aid airway clearance

PART 1: DIAGNOSTIC SPIROMETRY

Key Measurements

LLN = Lower Limit of Normal (statistically defined as 5th percentile of the reference population)

Interpretation Algorithm (Murray & Nadel's Textbook of Respiratory Medicine)

Step 1: Visually inspect the flow-volume curve
            ↓
Step 2: Check FEV1/FVC ratio
         ↙              ↘
    LOW (< LLN)        NORMAL or HIGH
    = Obstruction       ↓
         ↓          Check FVC
    Check FEV1       ↙        ↘
    ↙       ↘      Low        Normal
  Low     Normal   ↓           ↓
  Confirm  Early/  Restrictive  Normal spirometry
  Obstruct mild    defect       (get lung volumes
           obst    (confirm     to exclude
                   with TLC)    restriction)

• FEV1/FVC < LLN (< 0.70)
• FEV1 reduced
• FVC may be normal or low (air trapping)
• Flow-volume curve: concave (scooped) expiratory limb

• FEV1/FVC normal or elevated
• FVC low
• Confirmed by low TLC on full lung volume testing
• Flow-volume curve: narrow but preserved shape

• FEV1/FVC low AND FVC low
• Both obstructive and restrictive components

Performing Diagnostic Spirometry - Technique

1. Patient preparation: No smoking 4 hours prior, no bronchodilators (if testing bronchodilator response), no large meal, loose clothing
2. Position: Seated upright; nose clip applied
3. Mouthpiece: Tight seal, no air leak
4. Maneuver: Inhale maximally to TLC → blast out as forcefully and quickly as possible → continue exhaling for at least 6 seconds (minimum)
5. Acceptability criteria: Explosive start (PEF achieved within 100 ms), no cough in first second, no leak, exhalation ≥ 6 seconds
6. Reproducibility: Perform 3 acceptable maneuvers; best two FVC values within 150 mL of each other
7. Use post-bronchodilator values when airflow obstruction is suspected (Murray & Nadel's)

Bronchodilator Reversibility Test

• Administer salbutamol 400 mcg (4 puffs via MDI + spacer) or ipratropium 80 mcg
• Repeat spirometry after 15-20 minutes
• Significant reversibility: FEV1 or FVC increase by ≥ 200 mL AND ≥ 12% from baseline
• Positive reversibility suggests asthma over COPD

PART 2: INCENTIVE SPIROMETRY (IS)

What Is It?

Types of Incentive Spirometers

1. Volume-Oriented (Volume-Targeted) Spirometer

• Contains a piston chamber connected via corrugated hose and mouthpiece
• A one-way valve blocks exhalation into the device
• A slider is set to the target inspiratory volume
• The piston rises as the patient inhales, indicating inspired volume
• A smaller chamber with a ball measures the speed of inspiration (a ball rising to the top means the patient is breathing too fast - should be slow and sustained)
• Best for: Adults; provides precise volume feedback
• Examples: Voldyne 5000, Coach 2

2. Flow-Oriented (Flow-Targeted) Spirometer

• Contains 3 chambers in a row, each with a floating ball
• Each ball indicates the minimum flow needed to raise it (600-1200 mL/sec)
• Patient inhales to lift 1, 2, or all 3 balls
• More visual, gamified feedback
• Limitation: Does not directly measure volume; encourages high-flow (fast) inspiration which may not be as effective as slow, sustained effort
• Best for: Patients who need motivation feedback; pediatric/geriatric variants available (100-600 mL/sec range)

3. Pediatric / Geriatric Flow-Targeted Spirometer

• Flow settings from 100 mL/sec to 600 mL/sec
• Allows even weakened patients to achieve minimum inspiratory effort for effective therapy

Physiological Rationale

• Increases transpulmonary pressure → re-expands collapsed alveoli (reverses atelectasis)
• Increases functional residual capacity (FRC)
• Opens collateral ventilation channels (Pores of Kohn, Channels of Lambert) to ventilate alveoli behind mucus plugs
• Promotes mucociliary clearance
• Strengthens inspiratory muscles (diaphragm + external intercostals)

"This problem [atelectasis] is best resolved by increasing resting lung volume or FRC. The latter can be increased by an increase in transpulmonary pressure." - Barash Clinical Anesthesia, 9e

"Incentive spirometry and CPAP has been shown to reduce postoperative complications." - Barash Clinical Anesthesia, 9e

Indications

• Prevention and treatment of postoperative atelectasis
• Post-thoracic / abdominal / cardiac surgery
• LRTI with consolidation or retained secretions
• Non-cardiogenic pulmonary edema (to recruit alveoli)
• COPD exacerbation
• Neuromuscular disease with weak inspiratory muscles
• Prolonged bed rest / immobility
• Pre-operative pulmonary conditioning in high-risk patients

Contraindications / Precautions

How to Use Incentive Spirometer - Step-by-Step Technique

1. Exhale fully through the mouth to FRC (functional residual capacity) - do NOT use the device for exhalation
2. Seal lips tightly around the mouthpiece
3. Breathe in slowly, deeply, and steadily - the goal is a slow, sustained effort (not a fast blast)
4. Watch the indicator rise toward the target volume/level
5. Hold the breath at peak inspiration for 3-5 seconds (this is the most important step for alveolar recruitment - it allows collateral ventilation to occur)
6. Remove the mouthpiece and exhale normally through pursed lips
7. Rest (2-3 normal breaths) before the next repetition
8. Cough or huff after a set of 3-5 repetitions to expectorate mobilized secretions

Setting the Target Volume

Evidence Summary

IS in the Context of This Patient (Lactic Acidosis + NCPE + LRTI)

• Goal: Recruit edema-flooded and consolidation-collapsed alveoli to improve V/Q matching and oxygenation
• Frequency: 10 repetitions per hour while awake
• Key step: The 3-5 second inspiratory hold is mandatory - this is what drives collateral ventilation around fluid-filled alveoli
• Monitoring: Check SpO2 before and after each set; if it drops > 4%, increase nasal cannula flow first
• Combine with: ACBT and huff coughing immediately after IS sets to expectorate any mobilized secretions
• Precaution: If lactic acidosis is severe (rising lactate, pH < 7.25), IS is still safe as it is a low-effort passive respiratory exercise - but avoid vigorous exertion

Quick Comparison: Diagnostic vs. Incentive Spirometer

• Murray & Nadel's Textbook of Respiratory Medicine - Spirometry Interpretation Algorithm
• Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e - Atelectasis; Incentive Spirometry
• Miller's Anesthesia, 10e - Respiratory Failure; Postoperative Atelectasis
• Sabiston Textbook of Surgery - Atelectasis; Chest Wall Trauma
• StatPearls, NCBI NBK572114 - Incentive Spirometer and Inspiratory Muscle Training
• Chang et al. 2023 - Systematic Review/Meta-Analysis, PMID: 36437210
• Nasirmoghadas et al. 2025 - RCT, PMID: 39794689
• PRIME-AIR Trial 2025 - Phase 3 RCT, PMID: 40020692

Recent Guidelines on Spirometry Standards and Quality Criteria

1. ATS/ERS 2019 - Standardisation of Spirometry

Key Changes from the 2005 Standard

• Spirometers must now meet ISO 26782 standards with a maximum permissible accuracy error of ±2.5%
• End of Forced Expiration (EOFE) was redefined with three objective criteria
• Maneuver acceptability and repeatability criteria were updated
• Spirometry systems must provide uniform cues and feedback to the operator
• New withholding times for bronchodilators before testing
• New relative contraindications list added
• Device quality assurance procedures updated
• Operator training, competency attainment, and maintenance were formally addressed

Equipment Standards (ATS/ERS 2019)

Pre-Test Patient Preparation

Relative Contraindications (ATS/ERS 2019)

• Hemoptysis of unknown origin
• Pneumothorax (active or recent)
• Cardiovascular instability (recent MI, unstable angina, pulmonary embolism)
• Thoracic, abdominal, or cerebral aneurysm
• Recent thoracic, abdominal, or eye surgery
• Nausea or vomiting
• Confusion or dementia that prevents satisfactory cooperation

Within-Maneuver Acceptability Criteria (ATS/ERS 2019)

End of Forced Expiration (EOFE) - Redefined 2019

1. Expiratory plateau - change of ≤ 0.025 L in the last 1 second of expiration
2. Expiratory time ≥ 15 seconds
3. Patient cannot continue due to discomfort or lack of cooperation (documented)

Important exception: Patients with high elastic recoil (children) or restrictive lung disease may not achieve a plateau. In such cases, EOFE is met if the FVC is equal to or within repeatability tolerance of the largest FVC seen in prior maneuvers.

Between-Maneuver Repeatability Criteria (ATS/ERS 2019)

• If repeatability criteria are not met after 3 attempts, continue testing
• Maximum 8 attempts per session (pre- and post-bronchodilator separately)
• If acceptable results still cannot be obtained after 8 attempts, document and consider repeating on another day

Test Session Quality Grading System (ATS/ERS 2019)

"Although some maneuvers may be acceptable or usable at grading levels lower than A, the overriding goal of the operator must be to always achieve the best possible testing quality for each patient." - ATS/ERS 2019

2. ERS/ATS 2022 - Interpretive Strategies for Lung Function Tests

Major Paradigm Shift: Z-Scores and LLN Over % Predicted

Lower Limit of Normal (LLN)

• Defined as the 5th percentile of the reference population
• Corresponds to a Z-score of -1.64
• Z-scores below -1.64 indicate abnormality

"Z-scores lower than -1.64 (LLN < 5th percentile) indicate an abnormality. When interpreting results, there is a 5% chance a healthy individual may have results below the LLN - results should always be interpreted in clinical context." - ERS Respiratory Channel (2022 update)

Why % Predicted is Problematic

• The traditional 80% predicted cutoff is age, sex, and height-dependent
• It over-diagnoses disease in tall young men and under-diagnoses in short elderly women
• Z-scores are standardized across all demographics

Severity Classification Using Z-Scores (ERS/ATS 2022)

Bronchodilator Responsiveness (BDR) - Updated 2022

Positive BDR = increase in FEV1 or FVC by > 200 mL AND ≥ 12% from baseline

Positive BDR = increase of > 10% relative to the predicted value for FEV1 or FVC

"Previous term reversibility testing is discouraged as reversibility implies complete elimination of bronchial obstruction." - ERS/ATS 2022

Airway Obstruction: LLN vs. Fixed 0.70 Ratio

"FEV1/FVC ratio declines with increasing age and height, even in healthy lifelong non-smokers, in whom the LLN drops below a ratio of 0.7 after about 45 years of age. Thus the use of a fixed ratio causes over-diagnosis in elderly and under-diagnosis in younger patients." - ERS Channel, 2022 guidance

Long-Term Monitoring of Lung Function (2022)

• FEV1 is divided by the sex-specific 1st centile of FEV1 in adults with lung disease (FEV1Q)
• Changes within ±1.96 change scores are considered within normal limits
• This accounts for regression to the mean and test-retest variability

Race-Neutral Reference Equations - GLI-Global 2022

• Reclassification of ventilatory impairment for an estimated 12.5 million Americans
• Non-obstructive ventilatory impairment classifications may increase 141% among Black patients (previously under-diagnosed by race adjustment) and decrease 69% among White patients
• Both GLI-2012 and GLI-Global equations had similar clinical prediction accuracy - the main difference is who gets labelled as impaired, not predictive validity
• Annual disability payments could shift by over $1 billion between demographic groups

Key implication: GLI-Global equations are now recommended; applying race corrections to lower thresholds for Black patients is no longer considered appropriate.

3. ERS/ATS 2023 - Standardisation of Lung Volumes

• New acceptability and grading system for lung volume measurements (mirrors the spirometry grading system)
• Standardisation of linked spirometry (simultaneous measurement with body plethysmography)
• Updated equipment quality control and validation
• Generalized multiple breath washout beyond nitrogen washout
• Low TLC (< LLN) confirms restriction when FVC is reduced on spirometry - cannot diagnose restriction from spirometry alone

4. 2026 Practice Guideline: Recommendations for Performing Spirometry

• Technical requirements for equipment and facilities
• Operator training for adequate maneuver quality
• Quality grade of each test must be determined before interpretation
• Use of updated reference values appropriate for each patient group
• Standardization of post-bronchodilator testing is essential for diagnosing specific diseases

Summary Table: What Changed Across Guidelines

Key References

1. Pellegrino R, Viegi G, Brusasco V, et al. ATS/ERS Standardisation of Spirometry 2019 Update. Am J Respir Crit Care Med. 2019;200(8):e70-e88. PMC6794117 - the primary technical standard for performing spirometry
2. Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS Technical Standard: Interpretive Strategies for Routine Lung Function Tests. Eur Respir J. 2022. - z-scores, LLN, new BDR criterion, GLI-Global reference equations
3. Bhakta NR, McGowan A, Ramsey KA, et al. ERS/ATS Technical Statement: Standardisation of the Measurement of Lung Volumes, 2023 Update. Eur Respir J. 2023. PMID: 37500112
4. García-García R, et al. Recommendations for Performing Spirometry. Arch Bronconeumol. 2026. PMID: 41651752 - most recent practice guideline
5. Diao JA, He Y, Khazanchi R, et al. Implications of Race Adjustment in Lung-Function Equations. NEJM. 2024;390(23). PMID: 38767252 - landmark analysis of GLI-Global vs GLI-2012
6. Murray & Nadel's Textbook of Respiratory Medicine - Major Patterns on PFTs; ATS/ERS quality criteria (minimum 3 acceptable spirograms; two largest FVC and FEV1 within 150 mL)

Incentive Spirometer Exercises - Added to Treatment Plan

Why Incentive Spirometry is Indicated for This Patient

"The use of incentive spirometry and CPAP has been shown to reduce postoperative complications. Additional modalities that may be helpful include bronchodilator treatment, coughing, chest physiotherapy, and mobilizing the patient." - Barash Clinical Anesthesia, 9e

Lung expansion therapy using incentive spirometry improves diaphragm mobility and thickness, increases lung volume, improves pulmonary function, and decreases length of hospitalization. - Sankarganesh et al., 2023, Cureus (PMID: 38511105)

Incentive Spirometer Exercise Protocol

Phase 1: Days 5-7 (Acute Phase - Establishing the Routine)

• Begin at 500-750 mL or whatever volume the patient can comfortably achieve
• Set the indicator/slider at this level
• Increase by 100-200 mL every 24 hours as tolerated

The 3-5 second inspiratory hold is what makes IS effective - it allows time for collateral ventilation via the Pores of Kohn to open alveoli behind secretions and fluid.

IS Exercise Prescription by Phase

Key rule: The device should be used every waking hour. Put it in the patient's hand, visible on the bedside table as a reminder.

Combined IS + ACBT Session Protocol (2-3 × Daily with Physiotherapist)

1. BREATHING CONTROL (1 min)
   → Relaxed diaphragmatic breathing at own rate
         ↓
2. IS EXERCISE SET 1 (5 reps × 3-5 sec hold each)
   → Slow, deep, sustained inspiration to target volume
         ↓
3. BREATHING CONTROL (30-60 sec rest)
         ↓
4. THORACIC EXPANSION EXERCISES (3-4 deep breaths, 3-sec hold each)
   → Can do with or without IS device
         ↓
5. BREATHING CONTROL (30 sec)
         ↓
6. IS EXERCISE SET 2 (5 reps)
         ↓
7. FORCED EXPIRATION TECHNIQUE / HUFF (2-3 huffs)
   → Open glottis, mid-lung volume huff → expectorate secretions
         ↓
8. BREATHING CONTROL (1 min)
         ↓
9. PRODUCTIVE COUGH (if secretions reached central airways)

Monitoring During IS Exercise

Volume Progression Targets

Predicted Inspiratory Capacity for a 63-year-old woman (average height ~155-160 cm) ≈ 1800-2200 mL. Aim for ≥ 70% of this = 1260-1540 mL as a discharge readiness marker.

Patient Education Card for IS (Leave at Bedside)

✓ Sit upright
✓ Breathe all the way OUT first
✓ Seal lips on mouthpiece
✓ Breathe IN slowly - watch the ball/piston rise
✓ HOLD your breath 3-5 seconds at the top
✓ Take out mouthpiece, breathe out gently
✓ Rest 2-3 breaths, then repeat
✓ Do 5-10 repetitions per session
✓ After every 5 reps - try to cough or huff
✓ Keep the device upright at all times

IS in Context of Full Treatment Plan (Updated Summary)

Special Considerations for This Patient

• IS is inherently low-effort (inspiratory only) and does not meaningfully increase systemic oxygen demand
• Safe to continue even when lactate is mildly elevated (2-4 mmol/L)
• If lactate > 4 mmol/L and patient is hemodynamically unstable - reduce to gentle 3-rep sets only

• The slow, sustained inspiration of IS directly counteracts alveolar flooding by recruiting collapsed units
• IS is a non-pharmacological alveolar recruitment strategy equivalent to a low-level sustained inflation
• Works synergistically with positioning (HOB 30-45°)

• IS + huff combination is the most effective secretion clearance sequence
• Retained secretions in consolidation are mobilized by collateral ventilation opened during the IS hold phase
• Do not use IS during acute bronchospasm - give bronchodilator first, wait 15 minutes, then begin IS

References

• Barash, Cullen & Stoelting's Clinical Anesthesia, 9e - Atelectasis: "incentive spirometry and CPAP has been shown to reduce postoperative complications"
• Sabiston Textbook of Surgery - "atelectasis can be reversed in the first 24-48 hours with deep breathing (5 sequential breaths held 5-6 seconds), incentive spirometry, coughing"
• Sankarganesh A et al. Lung Expansion Therapy for the Potential Populations: A Literature Review. Cureus. 2023. PMID: 38511105 - IS improves diaphragm mobility, lung volume, and reduces hospital stay
• Chang PC et al. Incentive spirometry is an effective strategy to improve the quality of postoperative care. Asian J Surg. 2023. PMID: 36437210 - Meta-analysis: IS reduces PPCs by 32%, pneumonia by 17.9%, hospital stay by 1.8 days
• Nasirmoghadas A et al. Diaphragmatic breathing exercises and incentive spirometry in heart failure. BMC Cardiovasc Disord. 2025. PMID: 39794689 - IS reduced dyspnea score by 0.9 units at rest and 2.73 during activity (RCT)
• PRIME-AIR Trial. Perioperative lung expansion bundle. Lancet Respir Med. 2025. PMID: 40020692 - Supervised IS as part of bundle significantly reduced PPC severity (Phase 3 RCT, n=751)