Preoperative Incentive Spirometer to Prevent Postoperative Pulmonary Complications following Open Heart Surgeries: A Randomized Single Blinded Multi-Centric Clinical Trial


  • Jadeel Noor Faleh Al-Muthanah Health Directorate, Ministry of Health, Al-Muthanah, Iraq.
  • Sadeq AL-Fayyadh Adult Nursing Department, College of Nursing, University of Baghdad, Baghdad, Iraq.



Incentive Spirometer, Breathing Exercises, Postoperative Pulmonary Complications, Cardiac Surgery


Objectives: To determine the effect preoperative use of an Incentive Spirometer (IS) has on preventing postoperative pulmonary complications among patients undergoing open heart surgeries.

Methods: A prospective, randomized, controlled single-blinded parallel-group design. Data were collected from January 9th 2022 to April 1st  2022.  A total of n = 64 eligible patients were equally randomized to either intervention or control group. Patients in the intervention group performed preoperative IS training for two days before the scheduled surgery. The primary endpoint was the incidence of in-hospital PPCs. The secondary endpoints were postoperative Peak Expiratory Flow Rate (PEFR), Intensive Care Unit (ICU) stay, Hospital Length of Stay (HLOS).

Results: Patients in the intervention group had a lower incidence of postoperative pulmonary complications compared to the control group (12.5% and 21.8%). There was a statistical significant difference between the two groups regarding postoperative PEFR, HLOS and intensive care unit stay.

Conclusions: Preoperative rehabilitation (involving incentive spirometer is related to a lower incidence of postoperative pulmonary complications for the group that received the intervention. Training with preoperative incentive spirometer resulted in a shortening of hospital length of stay and Intensive Care Unit (ICU) stay.

Trial registration: The study was registered in the Iranian Clinical Trial Registry, this at reference number (IRCT20211224053503N1).


Tanner TG, Colvin MO. Pulmonary complications of cardiac surgery. Lung. 2020 Dec;198(6):889-96. Available from:

Mali S, Haghaninejad H. Pulmonary complications following cardiac surgery. Archives of Medical Science-Atherosclerotic Diseases. 2019 Dec 31;4(1):280-5. Available from:

Bharathi AR. Assess The Effectiveness of Deep Breathing Exercise with Incentive Spirometer on the Respiratory status of Cardio Thoracic and Vascular Patients. Journal of Research in Medical and Dental Science. 2021:276-83. Available from:

Fischer MO, Brotons F, Briant AR, Suehiro K, Gozdzik W, Sponholz C, Kirkeby-Garstad I, Joosten A, Neto CN, Kunstyr J, Parienti JJ. Postoperative Pulmonary Complications After Cardiac Surgery: The VENICE International Cohort Study. Journal of cardiothoracic and vascular anesthesia. 2022 Aug 1;36(8):2344-51. Available from:

Ubben JF, Lance MD, Buhre WF, Schreiber JU. Clinical strategies to prevent pulmonary complications in cardiac surgery: an overview. Journal of cardiothoracic and vascular anesthesia. 2015 Apr 1;29(2):481-90. Available from:

Jassim S, Ahmed SA, Nagi AB. Assessment of early and late complication post coronary artery graft by–pass surgery CABG. Kufa Journal for Nursing Sciences. 2013;3(1). Available from:

Mohammed AK, Nadr JH. Early complications associated with obesity following coronary artery bypass graft surgery. Journal of the Faculty of Medicine. 2021;63(4). Available from:

Rodrigues SN, Henriques HR, Henriques MA. Effectiveness of preoperative breathing exercise interventions in patients undergoing cardiac surgery: A systematic review. Revista Portuguesa de Cardiologia (English Edition). 2021 Mar 1;40(3):229-44. Available from:

Restrepo RD, Wettstein R, Wittnebel L, Tracy M. Incentive spirometry: 2011. Respiratory care. 2011 Oct 1;56(10):1600-4. Available from:

So MW, Heo HM, San Koo B, Kim YG, Lee CK, Yoo B. Efficacy of incentive spirometer exercise on pulmonary functions of patients with ankylosing spondylitis stabilized by tumor necrosis factor inhibitor therapy. The Journal of rheumatology. 2012 Sep 1;39(9):1854-8. Available from:

Sum SK, Peng YC, Yin SY, Huang PF, Wang YC, Chen TP, Tung HH, Yeh CH. Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: a randomized controlled trial. Trials. 2019 Dec;20(1):1-8. Available from:

Mohammad AM, Rashad HH, Habeeb QS, Rashad BH, Saeed SY. Demographic, clinical and angiographic profile of coronary artery disease in kurdistan region of Iraq. American Journal of Cardiovascular Disease. 2021;11(1):39. Available from:

Mousa AM, Mansour K. Effectiveness of an Instructional Program Concerning Healthy Lifestyle on Patients’ Attitudes after Percutaneous Coronary Intervention at Cardiac Centers in Baghdad City. Iraqi National Journal of Nursing Specialties. 2020 Sep 27;33(1):1-1. Available from:

Gheisari F, Emami M, Raeisi Shahraki H, Samipour S, Nematollahi P. The role of gender in the importance of risk factors for coronary artery disease. Cardiology Research and Practice. 2020 Jul 29;2020. Available from:

Alam M, Shehzad MI, Hussain S, Paras I, Kanwal M, Mushtaq A. Spirometry assessment and correlation with postoperative pulmonary complications in cardiac surgery patients. Cureus. 2020 Oct 23;12(10). Available from:

Katta N, Loethen T, Lavie CJ, Alpert MA. Obesity and coronary heart disease: epidemiology, pathology, and coronary artery imaging. Current problems in cardiology. 2021 Mar 1;46(3):100655. Available from:

Sharif-Kashani B, Shahabi P, Mandegar MH, Saliminejad L, Bikdeli B, Behzadnia N, Heydari G, Sharifi H, Aidanlou S. Smoking and wound complications after coronary artery bypass grafting. journal of surgical research. 2016 Feb 1;200(2):743-8. Available from:

Barua RS, Ambrose JA. Mechanisms of coronary thrombosis in cigarette smoke exposure. Arteriosclerosis, thrombosis, and vascular biology. 2013 Jul;33(7):1460-7. Available from:

Vitomskyi V, Al-Hawamdeh K, Lazarіeva О, Vitomskа M. The efficacy of using Tri-Ball breathing exerciser in respiratory function recovery of the patients undergoing cardiac surgery. Available from: doi:

Faritous Z, Yaghouti F, Ghadrdoost B, Heidarpour E, Ziyaeifard M. Transfusion of Blood Components and Postoperative Outcomes in Patients Undergoing Cardiac Surgery. Iranian Heart Journal. 2020 Apr 1;21(2):64-70. Available from:

Matsuura Y, Kamidaira M, Tamura A. Risk factors for postoperative delirium after cardiac surgery. Int Arch Nurs Health Care. 2018;4:103. Available from:

Chen X, Hou L, Zhang Y, Liu X, Shao B, Yuan B, Li J, Li M, Cheng H, Teng L, Guo M. The effects of five days of intensive preoperative inspiratory muscle training on postoperative complications and outcome in patients having cardiac surgery: a randomized controlled trial. Clinical rehabilitation. 2019 May;33(5):913-22. Available from:

Gilani SR, Hussain G, Ahmad N, Baig MA, Zaman H. Comparison of post-operative atelectasis in patients undergoing coronary artery bypass grafting with and without pre-operative incentive spirometry. Journal of Postgraduate Medical Institute. 2016 Apr 28;30(2). Available from:

Moradian ST, Heydari AA, Mahmoudi H. What is the role of preoperative breathing exercises in reducing postoperative atelectasis after CABG?. Reviews on recent clinical trials. 2019 Dec 1;14(4):275-9. Available from:

Hijas-Gómez AI. Preoperative Respiratory Physiotherapy and Postoperative Complications Following Valve Replacement Surgery. EC Pulmonology and Respiratory Medicine. 2017;4:92-100. Available from:

Herdy AH, Marcchi PL, Vila A, Tavares C, Collaço J, Niebauer J, Ribeiro JP. Pre-and postoperative cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery bypass surgery: a randomized controlled trial. American journal of physical medicine & rehabilitation. 2008 Sep 1;87(9):714-9. Available from: doi: 10.1097/PHM.0b013e3181839152. PMID: 18716482.

Savci S, Degirmenci B, Saglam M, Arikan H, Inal-Ince D, Turan HN, Demircin M. Short-term effects of inspiratory muscle training in coronary artery bypass graft surgery: a randomized controlled trial. Scandinavian cardiovascular journal. 2011 Oct 1;45(5):286-93. Available from: doi: 10.1097/PHM.0b013e3181839152. PMID: 18716482.

Hulzebos EH, Helders PJ, Favié NJ, De Bie RA, de la Riviere AB, Van Meeteren NL. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. Jama. 2006 Oct 18;296(15):1851-7. Available from: doi: 10.1001/jama.296.15.1851.

Nardi P, Pellegrino A, Pisano C, Vacirca SR, Anselmi D, Saulle S, Dandi R, Romano A, Servadio A, Gianlorenzi A, Ruvolo G. The effect of preoperative respiratory physiotherapy and motor exercise in patients undergoing elective cardiac surgery: short-term results. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2019 Jul;16(2):81-7. Available from: doi: 10.1001/jama.296.15.1851.

Shahood H, Pakai A, Rudolf K, Bory E, Szilagyi N, Sandor A, Zsofia V. The effect of preoperative chest physiotherapy on oxygenation and lung function in cardiac surgery patients: a randomized controlled study. Annals of Saudi Medicine. 2022 Jan;42(1):8-16. Available from:

Sobrinho MT, Guirado GN, Silva MA. Preoperative therapy restores ventilatory parameters and reduces length of stay in patients undergoing myocardial revascularization. Brazilian Journal of Cardiovascular Surgery. 2014 Apr; 29:221-8. Available from:




How to Cite

Noor Faleh, J. ., & AL-Fayyadh, S. . (2022). Preoperative Incentive Spirometer to Prevent Postoperative Pulmonary Complications following Open Heart Surgeries: A Randomized Single Blinded Multi-Centric Clinical Trial. Journal of Contemporary Medical Sciences, 8(4).