Comparative Effectiveness of Positive Expiratory Pressure Therapy versus Incentive Spirometry on Postoperative Pulmonary Function and Complications following Cardiopulmonary Surgery: Systematic Review and Meta-Analysis
DOI:
https://doi.org/10.55735/eyr2g145Keywords:
Chest physiotherapy , Deep breathing exercises, Incentive spirometry , Length of hospital stay , Positive expiratory pressure, Post-operative pulmonary complicationsAbstract
Background: Postoperative pulmonary complications are a significant issue in the aftermath of cardiopulmonary surgery, which often causes a rise in morbidity and prolonged hospitalization. Objective: To compare the effectiveness of Positive Expiratory Pressure therapy and Incentive Spirometry on pulmonary function and postoperative pulmonary complications in patients undergoing cardiopulmonary surgery. Methodology: This study systematically collates and synthesizes the findings of various randomized controlled trials. The meta-analytic method enables the combination of existing evidence, enhancing statistical power and providing a comprehensive evaluation of the interventions’ impacts. Some electronic databases, such as PubMed, Google Scholar, Cochrane Library, and Semantic, were used to conduct the literature search to identify controlled trials published between 2010 and 2024 among adult patients with postoperative cardiopulmonary complications. Results of all the included studies were analyzed, and the meta-analysis was conducted by Review Manager, and the Cochrane Risk of Bias 2 tool was used to evaluate the risk of bias of the included controlled trials bases of its five domains. Peer-reviewed studies containing a relevant outcome measure were included, whereas duplicates, non-English articles, studies with insufficient outcome data measures, or irrelevant procedures were not. Results: A total of 155 studies were identified, of which 141 were screened after duplicate removal. Title and abstract screening yielded nine full-text articles, and five studies met the eligibility criteria. The meta-analysis showed low-level evidence supporting Positive Expiratory Pressure therapy, with a statistically significant improvement in oxygen saturation compared to Incentive Spirometry (SMD=1.47; 95% CI: 0.07-2.87; p=0.004). However, no significant difference was found for peak expiratory flow rate, with high heterogeneity (I²=95%) and a non-significant pooled effect size (SMD=1.15; p=0.37), indicating no clear advantage of either intervention for PEFR. Conclusion: Positive Expiratory Pressure therapy is associated with significant improvement in oxygen saturation compared to Incentive Spirometry, while no significant difference was observed. Both therapies demonstrated comparable effectiveness, with heterogeneous and limited evidence.
Downloads
References
1. Jage B, Thakur A. Effectiveness of Acapella along with institution-based chest physiotherapy techniques on pulmonary functions and airway clearance in post-operative CABG patients. Hong Kong Physiotherapy Journal 2022; 42(2): 81–9.
https://doi.org/10.1142/S101370252250007X
2. Sriwannawit P, Aimrat A, Piramruk P, et al. Effects of positive expiratory pressure and breath stacking training on pulmonary function in cardiac surgery patients: a randomized controlled trial. Archives of Allied Health Sciences 2021; 33(3): 16–28.
3. Chaudhary S, Chaudhary NI, Ghewade B, et al. The immediate effects of breathing exercises with Acapella and an incentive spirometer on preventing early pulmonary complications following CABG: A comparative study. International Journal of Current Research and Review 2020; 12(17): 51–8.
http://doi.org/10.31782/IJCRR.2020.121710
4. Sullivan KA, Churchill IF, Hylton DA, Hanna WC. Use of incentive spirometry in adults following cardiac, thoracic, and upper abdominal surgery to prevent post-operative pulmonary complications: a systematic review and meta-analysis. Respiration 2021; 100(11): 1114–27.
http://doi.org/10.1159/000517012
5. Cho Y, Ryu H, Lee J, et al. A randomised controlled trial comparing incentive spirometry with the Acapella® device for physiotherapy after thoracoscopic lung resection surgery. Anaesthesia 2014; 69(8): 891–8.
https://doi.org/10.1111/anae.12750
6. Alam M, Hussain S, Shehzad MI, et al. Comparing the effect of incentive spirometry with Acapella on blood gases in physiotherapy after coronary artery bypass graft. Cureus 2020; 12(2): e6851.
https://doi.org/10.7759/cureus.6851
7. Zaman BA, Kiran V, Bhattacharjee B, Dutta A. Comparative Study on the Immediate Effects of Deep Breathing Exercises with PEP Device Versus Incentive Spirometry with EPAP on Preventing Pulmonary Complications Following CABG. International Journal of Physiotherapy 2016; 3(1): 140–6.
https://doi.org/10.15621/ijphy/2016/v3i1/88929
8. Gaonkar A, Naik VC. Effectiveness of Vibrapep (OPEP) on pulmonary functions in phase one of cardiac rehabilitation. A randomized controlled trial. Nepalese Heart Journal 2024; 21(2): 25–34.
https://doi.org/10.3126/nhj.v21i2.70865
9. Westerdahl E. Optimal technique for deep breathing exercises after cardiac surgery. Minerva Anestesiol 2015; 81(6): 678–83.
10. Eltorai AE, Szabo AL, Antoci Jr V, et al. Clinical effectiveness of incentive spirometry for the prevention of postoperative pulmonary complications. Respiratory Care 2018; 63(3): 347–52.
https://doi.org/10.4187/respcare.05679
11. Sweity EM, Alkaissi AA, Othman W, et al. Preoperative incentive spirometry for preventing postoperative pulmonary complications in patients undergoing coronary artery bypass graft surgery: a prospective, randomized controlled trial. Journal of Cardiothoracic Surgery 2021; 16(1): 241.
https://doi.org/10.1186/s13019-021-01628-2
12. Zafar MA, Hellmann M, Munshi A, et al. Effectiveness of a novel oral pep device vs incentive spirometry on lung aerations in postoperative atelectasis: a randomized pilot. Chest 2024; 166(4): A2774–A5.
https://doi.org/10.1016/j.chest.2024.06.1682
13. Leela A, Narayanan PT. Incentive spirometry prescription and inspiratory capacity recovery guideline for the early period after open-heart surgery. Faculty of Biosciences and Medical Engineering, Universiti Teknologi Malaysia; 2018.
14. Manapunsopee S, Thanakiatpinyo T, Wongkornrat W, et al. Effectiveness of incentive spirometry on inspiratory muscle strength after coronary artery bypass graft surgery. Heart, Lung and Circulation 2020; 29(8): 1180–86.
https://doi.org/10.1016/j.hlc.2019.09.009
15. Saliba KA, Blackstock F, McCarren B, et al. Effect of positive expiratory pressure therapy on lung volumes and health outcomes in adults with chest trauma: a systematic review and meta-analysis. Physical therapy 2022; 102(1): pzab254.
https://doi.org/10.1093/ptj/pzab254
16. Pieczkoski SM, de Oliveira AL, Haeffner MP, et al. Positive expiratory pressure in postoperative cardiac patients in intensive care: A randomized controlled trial. Clinical Rehabilitation 2021; 35(5): 681–91.
https://doi.org/10.1177/0269215520972701
17. Manoj et al. Effectiveness of incentive spirometry versus acapella in post coronary artery bypass grafting patients. International Journal of Creative Research Thoughts 2023; 11(5): K640–K652.
18. Kapadia S, Chokshi TR, Patel M. Effect of flutter along with conventional chest physiotherapy on peak expiratory flow rate among coronary artery bypass graft patients. Journal of the Scientific Society 2023; 50(2): 238–42.
https://doi.org/10.4103/jss.jss_213_22
19. Khar MN, Kausar R, Akbar R, et al. Effects of acapella versus blow bottle positive expiratory pressure on airway clearance and peak expiratory flow rate in post-COVID-19 patients. Journal of Health and Rehabilitation Research 2024; 4(1): 161–166.
https://doi.org/10.61919/jhrr.v4i1.355
20. Nadeem S, Khan HAR, Fatima M, et al. Comparing Incentive Spirometry with the Acapella Device for Physiotherapy after Thoracoscopic Lung Resection Surgery. Medical Journal of South Punjab (MJSP) 2023; 4(2): 14–22.
https://doi.org/10.61581/MJSP.VOL04/02/03
21. Reychler G, Uribe Rodriguez V, Hickmann CE, et al. Incentive spirometry and positive expiratory pressure improve ventilation and recruitment in postoperative recovery: a randomized crossover study. Physiotherapy Theory and Practice 2019; 35(3): 199–205.
https://doi.org/10.1080/09593985.2018.1443185
22. Urell C, Emtner M, Hedenström H, et al. Deep breathing exercises with positive expiratory pressure at a higher rate improve oxygenation in the early period after cardiac surgery: a randomised controlled trial. European Journal of Cardio-Thoracic Surgery 2011; 40(1): 162–67.
https://doi.org/10.1016/j.ejcts.2010.10.018
23. Kazemi M, Froutan R, Moghadam AB. Impact of inspiratory muscle training and positive expiratory pressure on lung function and extubation success of ICU patients: a randomized controlled trial. Archives of Academic Emergency Medicine 2024; 12(1): e59.
https://doi.org/10.22037/aaem.v12i1.2331
24. Malik PR, Fahim C, Vernon J, et al. Incentive spirometry after lung resection: a randomized controlled trial. The Annals of Thoracic Surgery 2018; 106(2): 340–45.
https://doi.org/10.1016/j.athoracsur.2018.03.051
25. Ahmad MA, Alaa Eldeen SMA, Youssef HA. Comparison of the effect of incentive spirometry and conservative therapy among open-heart surgery patients for the prevention of postoperative pulmonary complications. Assiut Scientific Nursing Journal 2014; 2(4.0): 105–18.
Downloads
Published
License
Copyright (c) 2026 Samina, Abdul Aziz, Mehkar Saleh, Hina Arshad, Muhammad Abdullah Abdullah
This work is licensed under a Creative Commons Attribution 4.0 International License.
How to Cite
0323-2274767