Advice for Physicians in Training: 40 Tips From 40 Docs


  • Uncertainty is everywhere in medicine – in diagnosis, prognosis and therapeutics. Be thankful for that, because without it, medicine would be algorithmic and boring. Uncertainty is where the science of medicine ends and the art of medicine begins.

David Juurlink, Advice for Physicians in Training: 40 Tips From 40 Docs,The Winnower2:e142006.67645 (2014). DOI:10.15200/winn.142006.67645

Guide to Incentive Spirometry

Guideline Recommendations for the use of Incentive Spirometry

The following recommendations are made following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) scoring system (Restrepo, 2010):

  1. Incentive spirometry alone is not recommended for routine use in the preoperative and postoperative setting to prevent postoperative pulmonary complications (1B).
  2. It is recommended that incentive spirometry be used with deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent postoperative pulmonary complications (1A).
  3. It is suggested that deep breathing exercises provide the same benefit as incentive spirometry in the preoperative and postoperative setting to prevent post-operative complications (2C).
  4. Routine use of incentive spirometry to prevent atelectasis in patients after upper-abdominal surgery is not recommended (1B).
  5. Routine use of incentive spirometry to prevent atelectasis after coronary artery bypass graft surgery is not recommended (1A).
  6. It is suggested that a volume-oriented device be selected as an incentive spirometry device (2B).


Incentive spirometry, also referred to as sustained maximal inspiration, is accomplished by using a device that provides feedback when the patient inhales at a predetermined flow or volume and sustains the inflation for at least 5 seconds. The patient is instructed to hold the spirometer in an upright position, exhale normally, and then place the lips tightly around the mouthpiece. The next step is a slow inhalation to raise the ball (flow-oriented) or the piston/plate (volume-oriented) in the chamber to the set target. At maximum inhalation, the mouthpiece is removed, followed by a breath-hold and normal exhalation. Instruction of parents, guardians, and other health caregivers in the technique of incentive spirometry may help to facilitate the patient’s appropriate use of the technique and assist with encouraging adherence to therapy.


  • 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).


  • 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)


Evidence is lacking for a specific frequency for use of incentive spirometry. Some suggestions have been made in clinical trials.

  • Ten breaths every one (Rafea et al., 2009) to two (Bellet et al., 1995) hours while awake
  • Ten breaths, 5 times a day (Renault et al., 2009)
  • Fifteen breaths every 4 hours (Kundra et al., 2010)

After proper instruction and return demonstration, the patient should be encouraged to perform incentive spirometry independently.




More Cases of “Superbug” Reported

Today several news outlets reported of patients recently becoming infected with a highly resistant “superbug” after exposure to endoscopic equipment. This “superbug” is Carbapenem-Resistant Enterobacteriaceae (CRE) and usually infects patients in hospitals, nursing homes, and other healthcare settings. These bacteria are highly resistant to many antibiotics and cause significant morbidity and mortality. Check out the links below to an article from The New York Times and the CDC’s webpage about CRE.

CDC – Carbapenem-Resistant Enterobacteriacae

“Superbug” Infects Hospital