An innovative method to do incentive spirometry in tracheostomized critically ill patients

Critically ill patients who have undergone tracheostomy represent a subset with challenges related to pulmonary complications such as atelectasis, hospital-acquired pneumonia, and respiratory muscle training. Factors such as prolonged immobilization, poor nutritional status, impaired mucociliary clearance, and critical illness polyneuromyopathy (CINM) all contribute to prolonged intensive care unit (ICU) stay. In such conditions inspiratory muscle training (IMT) is vital which helps by respiratory muscle strengthening, airway clearance and by increasing the pulmonary compliance.[1] Incentive spirometry is a device which helps by facilitating sustained maximal inspiration through engaging the diaphragm, inspiratory muscles and recruiting small airways thereby helping in overall pulmonary recovery. Among critically ill ICU patient’s spirometer helps in pulmonary rehabilitation by encouraging deep and controlled inspiration, expiration with subsequent pauses thus keeping small airways open and by increasing the tidal volume. Furthermore, it helps to achieve other goals of pulmonary rehabilitation by improving compliance, ventilation/perfusion mismatch, respiratory muscle strength thus decreasing ventilator dependence.[2] The use is restricted by and large for certain groups like those undergoing thoraco-abdominal surgery in which preoperative use of spirometer showed reduced risk of postoperative pulmonary complications.[2] Despite the clinical relevance, there is a paucity of literature regarding the use of spirometers in tracheostomized patients. To the best of our search, currently available commercial spirometers are not designed to meet their specific requirements. The major challenges include establishing an effective interface between the spirometer mouthpiece and the tracheostomy tube, standardizing the technique of use, and enabling concurrent oxygen supplementation. We propose a modification that also facilitates high-flow oxygen supplementation, making it potentially useful for mildly hypoxic, critically ill tracheotomized patients. A standard spirometry device (Romsons Breazer® 5000 volumetric respiratory exerciser, Romson Group Pvt. Ltd., India) was utilized. The mouthpiece was replaced with a catheter mount to connect with the 15 mm universal connector of the tracheostomy tube. An elbow connector from the breathing circuit was attached, with one end (15M) connected to the catheter mount and the other end (15/22 mm) connected to the spirometry device. In addition, the reservoir bag containing a one-way inspiratory valve and an oxygen inlet, taken from a nonrebreathing oxygen mask, was connected between the elbow connector and catheter mount using a T-piece connector (22M–22M–22F) [Figure 1A].Figure 1: Modified incentive spirometry attachments and technique for use. (A) Modified incentive spirometry attachments: (a) Incentive spirometer and elbow connector, (b) Elbow connector and T-connector, (c) Reservoir bag with one-way valve and T-connector, (d) Catheter mount (double swivel port) with T-connector. (B) Occlusion of double swivel port during maximal inspiration. (C) Release of double swivel port to facilitate expirationDuring the spirometry exercise, the oxygen tubing is connected to the reservoir bag, and the double-swivel port on the catheter mount is occluded by the respiratory therapist during maximal inspiration [Figure 1B]. The port is then released during expiration, allowing gas to escape [Figure 1C]. Several adaptations have been described by different authors. Goldstein et al. used a wye adapter with two arms; one connected to the spirometer and the other serving as an expiratory port. However, due to the larger diameter of the wye adapter, occlusion with the thumb may be inadequate, resulting in ineffective inspiration and suboptimal lung expansion.[3] Bloria et al. modified the device using a polyvinyl chloride (PVC) endotracheal tube, but the smaller internal diameter compared to the catheter mount increases inspiratory resistance and the work of breathing. In addition, the limited mobility of the PVC tube raises the risk of dislodgement. Expiration in this setup requires removal of the spirometer mouthpiece after each inspiration, making repeated detachment and reattachment difficult, painful, and restrictive for oxygen delivery.[4] Addressing these limitations, our modification employed a catheter mount with a double-swivel port and flip-top cap, which can be effectively occluded with the thumb during inspiration and easily released for expiration. In addition, the catheter mount, made of corrugated tubing with a double-swivel connector, provided enhanced mobility and flexibility, allowing 360° rotation of the spirometer for patient comfort and ease of use. Of the previous modifications, oxygen is delivered through either the wye adapter or the gas sampling port of the elbow connector, where only low-flow oxygen can be delivered.[3,4] Critically ill patients are prone to hypoxemia during pulmonary rehabilitation exercises which may offset improvements in exercise tolerance, thus limiting the benefits of rehabilitation. Supplementing oxygen in these patients will improve exercise tolerance and dyspnea. This was addressed by adding a reservoir bag to provide high-flow oxygen. However, providing high flow oxygen can also affect spirometers measurement of flow and volume achieved by overestimation. Hence, interpretation should be based on the serial trend of values obtained from the spirometer rather than a single reading. To evaluate the impact of volume-oriented spirometry, Ganesh et al. studied 30 patients with MRC score > 48 for 7 days and found improvement in lung volume and peak expiratory flow rate.[5] Our modification was applied in a 50-year-old female who was admitted with a history of fever and altered sensorium, and diagnosed to have meningoencephalitis on day of illness 1(D-1). During the course of illness patient developed CINM (MRC Score of 52) and was tracheostomized on D-16. In view of poor cough effort patient had retention of secretions and atelectasis which hampered liberation from mechanical ventilation. From D-25, our modification of volume-oriented spirometry was performed. Trained physiotherapist assisted the breathing exercise; the patient was asked to make an inspiratory effort and sustain it for a duration of 3–5 s. This was repeated for 10 successive cycles with a 30 s break between breaths which constituted one session. Two sessions were performed per day for 1 week. Mean Volume of air displaced (volume per breath) in the spirometer was measured at baseline which was 500 ml, then increased to 750 ml at the end of the 14th session. Patient was liberated from mechanical ventilation on D-36. Our additions are simple and include a catheter mount, an elbow connector, and a reservoir bag which are easily available in ICUs. However, this therapy is to be performed under the trained physiotherapist and also, and we propose clinical studies to assess its utility by integrating it in the weaning protocols of tracheotomized patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.