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CONCLUSIONS AND RELEVANCE Education and provision of incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. We would not recommend the addition of incentive spirometry to the current standard of care in this resource-constrained environment. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01789177. JAMA Surg . 2015;150(3):229-236. doi:10.1001/jamasurg.2014.1846 Published online January 21, 2015. CME Quiz at jamanetworkcme.com Author Affiliations: Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi (Tyson, Mabedi, Cairns, Charles); Department of Surgery, University of North Carolina School of Medicine, Chapel Hill (Tyson, Kendig, Charles); Gillings School of Global Public Health, University of North Carolina at Chapel Hill (Charles). Corresponding Author: Anthony G. Charles MD, MPH, Department of Surgery, University of North Carolina School of Medicine, 4008 Burnett Womack Bldg, CB 7228, Chapel Hill, NC 27599 ([email protected]). Research Original Investigation (Reprinted) 229
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Copyright 2015 American Medical Association. All rights reserved. P ostoperative pulmonary complications (PPC) follow- ing laparotomy are common and present a significant burden to health care systems by increasing health care costs, resource utilization, hospital length of stay, morbidity, and mortality. 1-5 The frequency of PPC after laparotomy re- ported in the literature varies widely, ranging from 20% to 90% for atelectasis and 9% to 40% for postoperative pneumonia. 3-16 Risk factors include older age, smoking, malnutrition, preop- erative or intraoperative blood loss, emergency surgery, and upper abdominal or thoracic surgery. 2-5,8,17-19 The functional mechanisms associated with the onset of PPC are not completely understood but likely involve a com- bination of decreased lung volume resulting in atelectasis and impaired mucociliary clearance. 1,4-6,17,18 Deep breathing and coughing exercises may help mobilize secretions and reex- pandareasofcollapsedlungpostoperatively.Theresultantsus- tained alveolar inflation and maintenance of normal func- tional residual capacity is thought to prevent PPC. 5 Incentive spirometry (IS) is a breathing technique in which deep breathing exercises are performed through a device of- fering visual feedback in terms of inspired flow and volume. The addition of visual feedback is thought to improve breath- ing technique and increase patient motivation. 20 Use of IS has gained substantial popularity in high-income countries since it was first introduced by Bartlett et al 20 in 1973 and is now con- sidered the standard of care in the postoperative period. 3,5,21 However, postoperative interventions to prevent PPC have demonstrated mixed results. Although some reviews have shown decreased incidence of PPC and length of stay in pa- tients using IS, 9 others have found little benefit from this intervention. 5,21,22 Data on PPC in low- and middle-income countries are scarce; however, the burden of health care–associated infec- tions in low- and middle-income countries is high. 23,24 Lim-
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