ガイドライン：Incentive Spirometry

“Incentive Spirometry：主として外科手術後の肺合併症の予防と治療を目的に，長い深呼吸を持続させるために「ため息」をさせる呼吸訓練器具の総称”
http://27.50.112.176/test/search/docs/103304001.pdf








AHRQ：Guideline Summary
http://guidelines.gov/content.aspx?f=rss&id=34793

Incentive spirometry: 2011.
Restrepo RD, Wettstein R, Wittnebel L, Tracy M. AARC clinical practice guideline: incentive spirometry: 2011. Respir Care 2011 Oct;56(10):1600-4. 


適応・禁忌をみると、Incentive spirometryは、深呼吸技術、直接的咳嗽、早期離床、適切な麻酔とともに使用することで、術後合併症予防に役立つかもしれない。ただ、単独使用のみは意味が無い。一定程度以上の肺活量、吸気を阻害する痛みや横隔膜機能障害がないこと、適切な麻酔が前提である。

【適応】

• Preoperative screening of patients at risk for post-operative complications to obtain baseline flow or volume (Agostini et al., 2008; Kips, 1997; Larson et al., 2009).
• Respiratory therapy that includes daily sessions of incentive spirometry plus deep breathing exercises, directed coughing, early ambulation, and optimal analgesia may lower the incidence of postoperative pulmonary complications.
• Presence of pulmonary atelectasis or conditions predisposing to the development of pulmonary atelectasis when used with:
  • Upper-abdominal or thoracic surgery (Westwood et al., 2007)
  • Lower-abdominal surgery (Pappachen et al., 2006)
  • Prolonged bed rest
  • Surgery in patients with chronic obstructive pulmonary disease (COPD)
  • Lack of pain control (Bellet et al., 1995)
  • Presence of thoracic or abdominal binders
  • Restrictive lung defect associated with a dysfunctional diaphragm or involving the respiratory musculature
    • Patients with inspiratory capacity 2.5 L (Weindler & Kiefer, 2001)
    • Patients with neuromuscular disease
    • Patients with spinal cord injury (Chureemas & Kovindha, 1992)
• Incentive spirometry may prevent atelectasis associated with the acute chest syndrome in patients with sickle cell disease (Bellet et al., 1995; Hsu, Batts, & Rau, 2005).
• In patients undergoing coronary artery bypass graft (Yánez-Brage et al., 2009)
  • Incentive spirometry and positive airway pressure therapy may improve pulmonary function and 6-minute walk distance and reduce the incidence of postoperative complications (Haeffener et al., 2008; Ferreira et al., 2010). 

【禁忌】

• Patients who cannot be instructed or supervised to assure appropriate use of the device
• Patients in whom cooperation is absent or patients unable to understand or demonstrate proper use of the device
  • Very young patients and others with developmental delays
  • Patients who are confused or delirious
  • Patients who are heavily sedated or comatose
• Incentive spirometry is contraindicated in patients unable to deep breathe effectively due to pain, diaphragmatic dysfunction, or opiate analgesia. (Wilkins, 2005)
• Patients unable to generate adequate inspiration with a vital capacity <10 mL/kg or an inspiratory capacity <33% of predicted normal (Wilkins, 2005) 

【ハザード・合併症】

• Ineffective unless performed as instructed
• Hyperventilation/respiratory alkalosis
• Hypoxemia secondary to interruption of prescribed oxygen therapy
• Fatigue
• Pain
  • Ineffective unless performed as instructed
  • Hyperventilation/respiratory alkalosis
  • Hypoxemia secondary to interruption of prescribed oxygen therapy
  • Fatigue
  • Pain 

 【評価・アウトカム評価】
１）incentive spirometry単独でのルーチン使用は、術前・術後の肺合併症予防のための使用として推奨しない（１B)

２）深呼吸技術、直接的咳嗽、早期離床、適切な麻酔とともに、incentive spirometryを使用することは、 術後肺合併症予防に対して推奨される。（１A)

３）術後合併症予防のため、術前・術後、深呼吸運動は、incentive spirometry使用と同様のベネフィットをみとめる。（２C)


４）上腹部手術のための、無気肺予防のためのincentive spirometryルーチン使用は推奨しない（１B)

５）冠動脈疾患バイパス術後のincentive spirometryルーチン使用は推奨しない（１A)

６）incentive spirometryデバイスとしてvolume-oriented deviceを選択すること（２B)