Development of a novel device for monitoring incentive spirometry performance

Lung atelectasis caused by shallow breathing patterns is common after cardiac, thoracic and upper abdominal surgeries. A common method used to address this problem is to encourage patients to perform breathing exercises using incentive spirometers in the postoperative period. However, to be effective, this procedure must be repeated regularly so that adequate lung volumes can be maintained to prevent atelectasis. Current models of single-use, low-cost incentive spirometers do not have features that can track and store data on breathing exercises. This makes it difficult to monitor patients’ breathing exercises effectively. We present here a device designed to be interfaced with the Spiro-ball incentive spirometer and programmed to monitor the incentive spirometry performance. Laboratory based validation performed indicate that there were no significant differences between the value obtained from the device and manual reading; p-value > 0.05 and root-mean-square error (RMSE) is 3.882. The device was able to retrieve and display pertinent data on incentive spirometry performance. It was also able to correctly track and register random sets of inspiration data through different dates and timelines. Being a separate entity which is reusable, it does not add to the cost of the single-use incentive spirometer

Improving the use of the 'COUGH' bundle in Surgical High Dependency Unit, Ninewells Hospital, Dundee

Developing respiratory complications postoperatively is one of the major determinants of longer hospital stay, morbidity, mortality and increased healthcare costs. The incidence of postoperative respiratory complications varies from 1% to 23%. Given that postoperative respiratory complications are relatively common and costly, there have been various studies which look at ways to reduce the risk of these occurring. One such protocol is the ICOUGH bundle which stands for Incentive spirometry, Coughing and deep breathing, Oral care, patient Understanding, Getting out of bed and Head of bed elevation. This has been adapted locally to the Coughing and deep breathing, Oral care, patient Understanding, Getting out of bed and Head of bed elevation (COUGH) bundle which consists of these components excluding incentive spirometry. Within our surgical high dependency unit (HDU), the COUGH bundle should be implemented in patients who have a moderate or high risk of developing postoperative respiratory complications with an Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score of 26 or above. Studies have shown that the ICOUGH bundle has reduced rates of pneumonia and unplanned intubation in general surgical and vascular patients. Baseline data taken from surgical HDU showed that the COUGH bundle was not well implemented. One out of eight patients who had an ARISCAT score greater than 26 had the COUGH bundle implemented on admission to the unit. Three out of eight patients had the ARISCAT score documented in their admission medical review. One patient who should have received the bundle, but did not, developed a hospital acquired pneumonia postoperatively. To address this issue, we aimed to increase awareness surrounding the COUGH bundle and to increase the number of patients who had the COUGH bundle started on admission. This quality improvement project had four cycles (plan, do, study, act) and after these, 100% of patients who had an ARISCAT score of 26 or more had the COUGH bundle implemented

Breathing SPACE – a practical approach to the breathless patient.

Breathlessness is a common symptom which may have multiple causes in any one individual and causes which may change over time. Breathlessness campaigns encourage people to see their GP if they are unduly breathless. Members of the London Respiratory Network collaborated to develop a tool which would encourage a holistic approach to breathlessness, which was applicable both at the time of diagnosis and during ongoing management. This has led to the development of the aide memoire “Breathing SPACE” which encompasses 5 key themes – Smoking, Pulmonary disease, Anxiety/psychosocial factors, Cardiac disease and Exercise/fitness. A particular concern was to ensure that high value interventions (smoking cessation and exercise interventions) are prioritised across the life-course and throughout the course of disease management. The approach is relevant both to well people and in those with an underling diagnosis or diagnoses. The inclusion of anxiety draws attention to the importance of mental health issues. Parity of esteem requires the physical health problems of people with mental illness to be addressed. The SPACE mnemonic also addresses the problem of underdiagnosis of heart disease in people with lung disease and vice versa, as well as the systematic undertreatment of these conditions where they do co-occur

Implementation of a guideline for physical therapy in the postoperative period of upper abdominal surgery reduces the incidence of atelectasis and length of hospital stay

Objective: the aim of this study was to evaluate the effectiveness of implementing a physical therapy guideline for patients undergoing upper abdominal surgery (UAS) in reducing the incidence of atelectasis and length of hospital stay in the postoperative period.Materials and methods: A before and after study design with historical control was used. the before period included consecutive patients who underwent UAS before guideline implementation (intervention). the after period included consecutive patients after guideline implementation. Patients in the pre-intervention period were submitted to a program of physical therapy in which the treatment planning was based on the individual experience of each professional. On the other hand, patients who were included in the post-intervention period underwent a standardized program of physical therapy with a focus on the use of additional strategies (EPAP, incentive spirometry and early mobilization).Results: There was a significant increase in the use of incentive spirometry and positive expiratory airway pressure after guideline implementation. Moreover, it was observed that early ambulation occurred in all patients in the post-intervention period. No patient who adhered totally to the guideline in the post-intervention period developed atelectasis. Individuals in the post-intervention period presented a shorter length of hospital stay (9.2 +/- 4.1 days) compared to patients in the pre-intervention period (12.1 +/- 8.3 days) (p< 0.05).Hosp Sirio Libanes, Rehabil Serv, São Paulo, BrazilUniv São Paulo, Sch Med, São Paulo, BrazilUniversidade Federal de São Paulo, Rehabil Serv, São Paulo, BrazilHosp Sirio Libanes, Phys Therapy Serv, São Paulo, BrazilUniversidade Federal de São Paulo, Rehabil Serv, São Paulo, BrazilWeb of Scienc

The UK quality and outcomes framework pay-for-performance scheme and spirometry: rewarding quality or just quantity? A cross-sectional study in Rotherham, UK

Background: Accurate spirometry is important in the management of COPD. The UK Quality and Outcomes Framework pay-for-performance scheme for general practitioners includes spirometry related indicators within its COPD domain. It is not known whether high achievement against QOF spirometry indicators is associated with spirometry to BTS standards. Methods: Data were obtained from the records of 3,217 patients randomly sampled from 5,649 patients with COPD in 38 general practices in Rotherham, UK. Severity of airflow obstruction was categorised by FEV1 (% predicted) according to NICE guidelines. This was compared with clinician recorded COPD severity. The proportion of patients whose spirometry met BTS standards was calculated in each practice using a random sub-sample of 761 patients. The Spearman rank correlation between practice level QOF spirometry achievement and performance against BTS spirometry standards was calculated. Results: Spirometry as assessed by clinical records was to BTS standards in 31% of cases (range at practice level 0% to 74%). The categorisation of airflow obstruction according to the most recent spirometry results did not agree well with the clinical categorisation of COPD recorded in the notes (Cohen's kappa = 0.34, 0.30 - 0.38). 12% of patients on COPD registers had FEV1 (% predicted) results recorded that did not support the diagnosis of COPD. There was no association between quality, as measured by adherence to BTS spirometry standards, and either QOF COPD9 achievement (Spearman's rho = -0.11), or QOF COPD10 achievement (rho = 0.01). Conclusion: The UK Quality and Outcomes Framework currently assesses the quantity, but not the quality of spirometry

Validation of chronic obstructive pulmonary disease recording in the Clinical Practice Research Datalink (CPRD-GOLD)

Objectives: The optimal method of identifying people with chronic obstructive pulmonary disease (COPD) from electronic primary care records is not known. We assessed the accuracy of different approaches using the Clinical Practice Research Datalink, a UK electronic health record database. Setting: 951 participants registered with a CPRD practice in the UK between 1 January 2004 and 31 December 2012. Individuals were selected for ≥1 of 8 algorithms to identify people with COPD. General practitioners were sent a brief questionnaire and additional evidence to support a COPD diagnosis was requested. All information received was reviewed independently by two respiratory physicians whose opinion was taken as the gold standard. Primary outcome measure: The primary measure of accuracy was the positive predictive value (PPV), the proportion of people identified by each algorithm for whom COPD was confirmed. Results: 951 questionnaires were sent and 738 (78%) returned. After quality control, 696 (73.2%) patients were included in the final analysis. All four algorithms including a specific COPD diagnostic code performed well. Using a diagnostic code alone, the PPV was 86.5% (77.5-92.3%) while requiring a diagnosis plus spirometry plus specific medication; the PPV was slightly higher at 89.4% (80.7-94.5%) but reduced case numbers by 10%. Algorithms without specific diagnostic codes had low PPVs (range 12.2-44.4%). Conclusions: Patients with COPD can be accurately identified from UK primary care records using specific diagnostic codes. Requiring spirometry or COPD medications only marginally improved accuracy. The high accuracy applies since the introduction of an incentivised disease register for COPD as part of Quality and Outcomes Framework in 2004

Perioperative Management of Pancreaticoduodenectomy

　The importance of perioperative management in pancreaticoduodenectomy has trebled, as the size of the elderly population continues to increase yearly. Recently, in our department, 17.6 percent of 159 patients undergoing pancreaticoduodenectomy were 75 years or older. Of greatest concern is the prevention of postoperative pneumonia. We have obtained favorable results through preoperative care by having patients strengthen respiratory muscles through incentive spirometry, practice walking, going up and down stairs, and practice expectoration of sputum using tissues. In postoperative care, we consistently apply, whenever appropriate, tapping and vibration to the entire back, prone therapy, and hyperbaric oxygen therapy, among other things. In preparation for surgery, we make the patient conscious of the imminent major surgery, as the patient must exhibit a strong will and readiness to fight the disease. This article also explains the importance and methods of drain placement and continuous lavage of the drains in relation to pancreaticoduodenectomy.（Kimura in Geka（Nankodo. Co）74: 1091-1095, 2012

Incentivador respiratório em cirurgias de grande porte: uma revisão sistemática

OBJECTIVE: To conduct a systematic review to evaluate the evidence of the use of incentive spirometry (IS) for the prevention of postoperative pulmonary complications and for the recovery of pulmonary function in patients undergoing abdominal, cardiac and thoracic surgeries. METHODS: Searches were performed in the following databases: Medline, Embase, Web of Science, PEDro and Scopus to select randomized controlled trials which the IS was used in pre- and/or post-operative in order to prevent postoperative pulmonary complications and/or recover lung function after abdominal, cardiac and thoracic surgery. Two reviewers independently assessed all studies. In addition, the studies quality was assessed using the PEDro scale. RESULTS: Thirty studies were included (14 abdominal, 13 cardiac and 3 thoracic surgery; n=3,370 patients). In the analysis of the methodological quality, studies achieved a PEDro average score of 5.6, 4.7 and 4.8 points in abdominal, cardiac and thoracic surgeries, respectively. Five studies (3 abdominal, 1 cardiac and 1 thoracic surgery) compared the effect of the IS with control group (no intervention) and no difference was detected in the evaluated outcomes. CONCLUSION: There was no evidence to support the use of incentive spirometry in the management of surgical patients. Despite this, the use of incentive spirometry remains widely used without standardization in clinical practice.OBJETIVO: Realizar um levantamento da literatura para avaliar as evidências do uso do incentivador respiratório (IR) na prevenção de complicações pulmonares pós-operatórias (CPPs) e recuperação da função pulmonar em pacientes submetidos a cirurgias abdominal, cardíaca e torácica. MÉTODOS: Esta revisão sistemática utilizou as bases de dados Medline, Embase, Web of Science, PEDro e Scopus para selecionar ensaios clínicos randomizados, nos quais o IR foi utilizado nos período pré e/ou pós-operatório, visando prevenir CPP e/ou recuperar função pulmonar após cirurgias abdominal, cardíaca ou torácica. Dois revisores analisaram independentemente os estudos. Além disso, a qualidade dos estudos foi avaliada segundo a escala PEDro. RESULTADOS: Trinta estudos foram incluídos (14 de cirurgia abdominal, 13 de cardíaca e três de torácica; n=3370 pacientes). Na análise de qualidade, os estudos obtiveram média de 5,6, 4,7 e 4,8 pontos nas cirurgias abdominais, cardíacas e torácicas, respectivamente. Cinco estudos (três de cirurgia abdominal, um de cardíaca e um de torácica) compararam o efeito do IR com grupo controle (sem intervenção) e não se verificou diferença nos desfechos estudados. CONCLUSÃO: Não se encontraram evidências que subsidiem o uso do IR no manejo de pacientes cirúrgicos. Apesar disso, o uso do IR continua não-padronizado e amplamente difundido na prática clínica.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

ACUTE EFFECTS OF VOLUME-ORIENTED INCENTIVE SPIROMETRY ON CHEST WALL VOLUMES IN PATIENTS AFTER STROKE.

The aim of the present study was to assess how volume-oriented incentive spirometry (IS) applied to patients after stroke modify total and compartmental chest wall volume variations, including right and left hemithorax compared to controls.20 post-stroke patients (stroke group, SG) and 20 age-matched healthy subjects (control group, CG) were studied by optoelectronic plethysmography during spontaneous quiet breathing (QB), IS and in the recovery period after IS.IS determined an increase of chest wall volume and its rib cage and abdominal compartments in both groups (p = 0.0008) and between the three instances (p < 0.0001). Compared to healthy control subjects, tidal volume of patients with stroke was 24.7\%, 18\% and 14.7\% lower during QB, , IS and post-IS, respectively. In all the three conditions the contribution of the abdominal compartment to tidal volume was greater in the stroke patients (54.1, 43.2 and 48.9\%) than controls (43.7, 40.8 and 46.1\%, p = .039). In the vast majority of patients 13/20 and 18/20 during QB and IS, respectively), abdominal expansion led rib cage expansion during inspiration. A greater asymmetry between the right and left hemithoracic expansion occurred in stroke patients compared to controls but it decreased during IS (62.5\% (p = 0.0023) QB; 19.7\% IS; and 67.6\% (p = 0.135) post-IS.IS promotes an increased expansion in all compartments of the chest wall and reduces the asymmetric expansion between right and left pulmonary rib cage and therefore it should be considered as a tool for rehabilitation