Effect of Incentive Spirometry on Postoperative Hypoxemia and Pulmonary Complications After Bariatric Surgery: A Randomized Clinical Trial

Haddon Pantel, John Hwang, David Brams, Thomas Schnelldorfer, Dmitry Nepomnayshy, Haddon Pantel, John Hwang, David Brams, Thomas Schnelldorfer, Dmitry Nepomnayshy

Abstract

Importance: The combination of obesity and foregut surgery puts patients undergoing bariatric surgery at high risk for postoperative pulmonary complications. Postoperative incentive spirometry (IS) is a ubiquitous practice; however, little evidence exists on its effectiveness.

Objective: To determine the effect of postoperative IS on hypoxemia, arterial oxygen saturation (Sao2) level, and pulmonary complications after bariatric surgery.

Design, setting, and participants: A randomized noninferiority clinical trial enrolled patients undergoing bariatric surgery from May 1, 2015, to June 30, 2016. Patients were randomized to postoperative IS (control group) or clinical observation (test group) at a single-center tertiary referral teaching hospital. Analysis was based on the evaluable population.

Interventions: The controls received the standard of care with IS use 10 times every hour while awake. The test group did not receive an IS device or these orders.

Main outcomes and measures: The primary outcome was frequency of hypoxemia, defined as an Sao2 level of less than 92% without supplementation at 6, 12, and 24 postoperative hours. Secondary outcomes were Sao2 levels at these times and the rate of 30-day postoperative pulmonary complications.

Results: A total of 224 patients (50 men [22.3%] and 174 women [77.7%]; mean [SD] age, 45.6 [11.8] years) were enrolled, and 112 were randomized for each group. Baseline characteristics of the groups were similar. No significant differences in frequency of postoperative hypoxemia between the control and test groups were found at 6 (11.9% vs 10.4%; P = .72), 12 (5.4% vs 8.2%; P = .40), or 24 (3.7% vs 4.6%; P = .73) postoperative hours. No significant differences were observed in mean (SD) Sao2 level between the control and test groups at 6 (94.9% [3.2%] vs 94.9% [2.9%]; P = .99), 12 (95.4% [2.2%] vs 95.1% [2.5%]; P = .40), or 24 (95.7% [2.4%] vs 95.6% [2.4%]; P = .69) postoperative hours. Rates of 30-day postoperative pulmonary complications did not differ between groups (8 patients [7.1%] in the control group vs 4 [3.6%] in the test group; P = .24).

Conclusions and relevance: Postoperative IS did not demonstrate any effect on postoperative hypoxemia, Sao2 level, or postoperative pulmonary complications. Based on these findings, the routine use of IS is not recommended after bariatric surgery in its current implementation.

Trial registration: clinicaltrials.gov Identifier: NCT02431455.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure.. Flow Diagram of the Study Design
Figure.. Flow Diagram of the Study Design
IS indicates incentive spirometry; Sao2, arterial oxygen saturation level.

References

    1. World Health Organization. Obesity and overweight. . Udpated June 2016. Accessed December 8, 2016.
    1. Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822-1832.
    1. Pasulka PS, Bistrian BR, Benotti PN, Blackburn GL. The risks of surgery in obese patients. Ann Intern Med. 1986;104(4):540-546.
    1. Rothen HU, Sporre B, Engberg G, Wegenius G, Hedenstierna G. Airway closure, atelectasis and gas exchange during general anaesthesia. Br J Anaesth. 1998;81(5):681-686.
    1. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. Chest. 2001;120(3):971-978.
    1. Sprung J, Whalley DG, Falcone T, Warner DO, Hubmayr RD, Hammel J. The impact of morbid obesity, pneumoperitoneum, and posture on respiratory system mechanics and oxygenation during laparoscopy. Anesth Analg. 2002;94(5):1345-1350.
    1. Bartlett RH, Krop P, Hanson EL, Moore FD. Physiology of yawning and its application to postoperative care. Surg Forum. 1970;21:222-224.
    1. O’Donohue WJ., Jr National survey of the usage of lung expansion modalities for the prevention and treatment of postoperative atelectasis following abdominal and thoracic surgery. Chest. 1985;87(1):76-80.
    1. Wattie J. Incentive spirometry following coronary artery bypass surgery. Physiotherapy. 1998;10(84):508-514.
    1. Awad S, Carter S, Purkayastha S, et al. . Enhanced Recovery After Bariatric Surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre. Obes Surg. 2014;24(5):753-758.
    1. Freitas ER, Soares BG, Cardoso JR, Atallah AN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev. 2007;(3):CD004466.
    1. Nickerson BG, Sarkisian C, Tremper K. Bias and precision of pulse oximeters and arterial oximeters. Chest. 1988;93(3):515-517.
    1. Majumdar SR, Eurich DT, Gamble JM, Senthilselvan A, Marrie TJ. Oxygen saturations less than 92% are associated with major adverse events in outpatients with pneumonia: a population-based cohort study. Clin Infect Dis. 2011;52(3):325-331.
    1. Gruber P, Kwiatkowski T, Silverman R, Flaster E, Auerbach C. Time to equilibration of oxygen saturation using pulse oximetry. Acad Emerg Med. 1995;2(9):810-815.
    1. Brown JT, Schur MS, McClain BC, Kafer ER. In vivo response time of transcutaneous oxygen measurement to changes in inspired oxygen in normal adults. Can Anaesth Soc J. 1984;31(1):91-96.
    1. Chiumello D, Coppola S, Froio S, et al. . Time to reach a new steady state after changes of positive end expiratory pressure. Intensive Care Med. 2013;39(8):1377-1385.
    1. Ahmad S, Nagle A, McCarthy RJ, Fitzgerald PC, Sullivan JT, Prystowsky J. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2008;107(1):138-143.
    1. Zoremba M, Dette F, Gerlach L, Wolf U, Wulf H. Short-term respiratory physical therapy treatment in the PACU and influence on postoperative lung function in obese adults. Obes Surg. 2009;19(10):1346-1354.
    1. Sucandy I, Szomstein S, Rosenthal RJ. Understanding the reasons and significance of low oxygen saturation in the early postoperative period after laparoscopic Roux-en-Y gastric bypass. Am Surg. 2013;79(5):540-541.
    1. Ralston AC, Webb RK, Runciman WB. Potential errors in pulse oximetry, I: pulse oximeter evaluation. Anaesthesia. 1991;46(3):202-206.
    1. Cattano D, Altamirano A, Vannucci A, Melnikov V, Cone C, Hagberg CA. Preoperative use of incentive spirometry does not affect postoperative lung function in bariatric surgery. Transl Res. 2010;156(5):265-272.
    1. Tyson AF, Kendig CE, Mabedi C, Cairns BA, Charles AG. The effect of incentive spirometry on postoperative pulmonary function following laparotomy: a randomized clinical trial. JAMA Surg. 2015;150(3):229-236.
    1. Spaniolas K, Kasten KR, Sippey ME, Pender JR, Chapman WH, Pories WJ. Pulmonary embolism and gastrointestinal leak following bariatric surgery: when do major complications occur? Surg Obes Relat Dis. 2016;12(2):379-383.
    1. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis. 1984;130(1):12-15.
    1. Craven JL, Evans GA, Davenport PJ, Williams RH. The evaluation of the incentive spirometer in the management of postoperative pulmonary complications. Br J Surg. 1974;61(10):793-797.

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