CONCLUSIONS AND RELEVANCEEducation and provision of incentive spirometry forunmonitored patient use does not result in statistically significant improvement in pulmonarydynamics following laparotomy. We would not recommend the addition of incentivespirometry to the current standard of care in this resource-constrained environment.TRIAL REGISTRATIONclinicaltrials.gov Identifier: NCT01789177.JAMA Surg. 2015;150(3):229-236. doi:10.1001/jamasurg.2014.1846Published online January 21, 2015.CME Quizatjamanetworkcme.comAuthor Affiliations:Department ofSurgery, Kamuzu Central Hospital,Lilongwe, Malawi (Tyson, Mabedi,Cairns, Charles); Department ofSurgery, University of North CarolinaSchool of Medicine, Chapel Hill(Tyson, Kendig, Charles); GillingsSchool of Global Public Health,University of North Carolina at ChapelHill (Charles).Corresponding Author:Anthony G.Charles MD, MPH, Department ofSurgery, University of North CarolinaSchool of Medicine, 4008 BurnettWomack Bldg, CB 7228, Chapel Hill,NC 27599 ([email protected]).ResearchOriginal Investigation(Reprinted)229
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Copyright 2015 American Medical Association. All rights reserved.Postoperative pulmonary complications (PPC) follow-ing laparotomy are common and present a significantburden to health care systems by increasing health carecosts, resource utilization, hospital length of stay, morbidity,and mortality.1-5The 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.3-16Risk factors include older age, smoking, malnutrition, preop-erative or intraoperative blood loss, emergency surgery, andupper abdominal or thoracic surgery.2-5,8,17-19The functional mechanisms associated with the onset ofPPC are not completely understood but likely involve a com-bination of decreased lung volume resulting in atelectasis andimpaired mucociliary clearance.1,4-6,17,18Deep breathing andcoughing 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.5Incentive spirometry (IS) is a breathing technique in whichdeep 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.20Use of IS hasgained substantial popularity in high-income countries sinceit was first introduced by Bartlett et al20in 1973 and is now con-sidered the standard of care in the postoperative period.3,5,21However, postoperative interventions to prevent PPC havedemonstrated mixed results. Although some reviews haveshown decreased incidence of PPC and length of stay in pa-tients using IS,9others have found little benefit from thisintervention.5,21,22Data on PPC in low- and middle-income countries arescarce; however, the burden of health care–associated infec-tions in low- and middle-income countries is high.23,24Lim-
Test, Randomized controlled trial, American Medical Association
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