Role of Incentive Spirometry in Tracheostomised Patients in ICU

INTRODUCTION: The incentive spirometry is a medical device used to improve the functioning of the lungs by facilitating lung expansion and strengthening of respiratory muscles.(1) It is commonly used after surgery and certain illness to prevent pulmonary complications. CASE REPORT: A 56 year old male with no comorbidities had complaints of fever and shortness of breath of 3 days duration was shifted to our ICU in view of worsening oxygenation. He was initiated on BiPAP with high FIO2. In view of worsening respiratory distress and oxygenation he was intubated and ventilated. ABG showed severe hypoxemia (PaO2/FiO2 ratio less than 100) and was diagnosed to have ARDS. He was started on antibiotics, anti virals steroids and nebulization. The respiratory viral panel tested positive for influenza A. He underwent two cycles of proning each for a duration of 36 hours. There was a gradual improvement in the oxygenation and markers also showed a decreasing trend. He was weaned to pressure support mode. Percutaneous tracheostomy was done after 20 days of mechanical ventilation. Chest physiotherapy was initiated and continued. NIV trials were started after a week following tracheostomy. Weaning from ventilator was prolonged and we were facing difficulty in weaning to BIPAP from PS mode. We initiated a novel technique of using incentive spirometry(2) for the patient with a tracheostomy. This needs an endotracheal tube(3), 15mm universal connector, an adaptor provided with the oxygen supplementation. We had used the endotracheal tube as a mediator, placed in between the spirometry and the patient's tracheostomy end.(4) After positioning the patient in the upright posture, instructed the patient to take the deep maximal inspiration and hold it for 2 to 4 seconds followed by expiration.(5) Patient was very cooperative and compliance was good. Weaning progressed faster and patient was weaned to BIPAP continuously.(6) Later he could be weaned to intermittent Thermovent with minimal oxygen requirement. The patient also received rehabilitation including limb physiotherapy and tracheostomy care and high protein diet was also initiated. Patient was shifted to ward and was discharged after 2 months stay in the hospital. DISCUSSION: The weaning phase of the tracheostomy remains challenging for the Intensivists. The usage of incentive spirometry for the Tracheostomy patients made an established therapy. Few studies had enlightened the need of it. Malhotra et al and Goldstein et al had suggested the use of wye adaptor as a mediator. We had modified it with the endotracheal tube. CONCLUSION: This technique helps to recruit the alveoli, improves the functional residual capacity and strengthening of respiratory muscles. It helps in weaning patient from ventilator and also reducing the length of ICU stay.