Do You Suck or Blow? Rethinking Incentive Spirometry

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Introduction

As nurses, we've all been there, entering a patient's room during rounds, glancing at the bedside table, and spotting that familiar plastic breathing device sitting there in all its glory.

We usually already know the answer before we even ask, "Have you been using your incentive spirometer (IS)?"

But this time, a mildly forgetful elderly patient responded with a question, instead of an answer. In his loud, no-hearing-aid voice, he exclaimed, "Do you suck or blow?!" Desperately trying not to laugh out loud, I bent down to eye level and replied, 'You have to suck so the balls rise.' I instantly realized how wrong that sounded and held back my laughter. After what seemed like an eternity, the patient finally grasped the concept.

As I quickly left his room and glanced at my watch, I realized it was time to clock out, but room four needed a bedpan, room five wanted a snack, and as I sat at the computer trying to finish charting, call lights rang like a symphony.

This moment made me laugh, but it also made me reflect. Are we doing this because it works, or just because it’s routine? What if we could streamline this entire interaction and reclaim that time for more meaningful care?

Here's the point: since the 1990s, research has challenged the assumption that IS reduces postoperative pulmonary complications (PPCs) or shortens hospital stays. Despite this, many hospitals continue to hand one out to every post-op patient, often without considering individual risk factors or likely benefits. (Kotta & Ali, 2020)

Why, you may ask? Habit, maybe. Or the comfort of routine. Or maybe it's the quiet momentum of the IS industry, projected to reach 2.7 billion by 2030.(Larsen et al., 2022) Or maybe you’ve heard, “Because that’s the way we’ve done it for years…”

In today’s healthcare environment, where nurses run with skeleton crews and every minute and dollar counts, it’s time to re-evaluate this practice. Not to discard IS entirely, but to consider approaching its use differently. Many hospitals have probably not reviewed or updated their incentive spirometer protocols in some time. So, finding out if your hospital is “blanket-giving” them out to all post-surgical patients routinely is the main question at hand. (Kotta & Ali, 2020)

This article isn’t about pointing fingers or saying who’s right or wrong. It’s about empowering nurses to be change agents, to be the movers and shakers, to be curious about the current evidence, and to tailor individualized care to improve cost-effectiveness and care efficiency.

So, let’s talk about who actually benefits from incentive spirometers, who doesn’t, and what it might look like to implement a change in your unit. But first, a brief history.

A Brief History of IS

Originally introduced to reduce the incidence of atelectasis, the incentive spirometer gained traction in the 1970s and '80s.(Ababneh et al., 2025) The small medical apparatus made of plastic helped post-surgical patients breathe deeply. It was thought that encouraging deep breathing postoperatively would help patients reopen collapsed alveoli and prevent complications like the flu and pneumonia. Over time, IS became a standard part of surgical recovery protocols, often without accompanying evidence-based data to support its blanket use. (Kotta & Ali, 2020) The device was simple, inexpensive, and easy to implement. But like many interventions in healthcare, it slowly transitioned from an evidence-informed intervention to an unquestioned standard of care.

The Evidence Rollercoaster

The first medical articles on IS skepticism began surfacing in the 1990s. A 2014 Cochrane review by do Nascimento Jr. et al. concluded that incentive spirometry did not prevent postoperative pulmonary complications.

Fun Fact: When someone references a Cochrane Review, it's a big deal. These are considered the gold standard in healthcare research due to their rigorous methodology.(Cipriani et al., 2011)

What the Latest Studies Say

Since then, several studies as recent as 2024 have echoed these findings, showing no significant benefit regarding length of stay, postoperative oxygen saturation, or pulmonary complication rates- even in high-risk post-op lung cancer patients.(Casiraghi et al., 2024) Another research article published just last year did not show promising IS results for post-cardiac patients when compared to standard respiratory care. (Silva et al., 2024)

And it doesn’t end there. More recent research highlights subsets of patients who do seem to benefit. Recent 2025 studies have found positive outcomes in patients undergoing upper abdominal surgeries and in those recovering from COVID-19 or experiencing long COVID, suggesting that targeted use could still hold value.(Ababneh et al., 2025; Chen & Hsieh, 2024) The evidence remains mixed, but not meaningless.

Indication Creep: How IS Became Default

This pattern, known as "indication creep," occurs when a treatment originally intended for specific patients gradually becomes standard for all. (Riggs & Ubel, 2014) For example, a tool meant for post-thoracic patients may now be given to every post-op, regardless of risk. In the case of IS, that creep may have left us with a practice that is more habit than healing.

Why This Matters

Since the Pandemic, healthcare has been under financial pressure. Hospitals continually search for ways to cut costs and optimize workflows. Nurses are expected to do more with less, and since time is a huge factor, each intervention must earn its rightful place in the care plan. Every minute spent on an unnecessary intervention is time that could be spent on other important tasks: on helping a patient ambulate, on wound care, on education, or simply listening to a patient.

Consider the time saved by not needing to enter the room just to provide IS education. We all know that when we go in to provide IS education, we’re not just providing the education, but we're also fetching them warm blankets and fielding a growing list of random requests.

The cost of an incentive spirometer is around $12. It may not seem like much, but multiply that by hundreds of surgeries each month, and when you add the nurse and respiratory therapist time required to educate patients on its use, the cost to implement IS in the United States is estimated to be 1.04 billion dollars annually. (Eltorai et al., 2018) With the recent executive orders on tariffs, researchers are forecasting an increase in the cost of healthcare and potential supply chain issues, which could increase the price of incentive spirometers. (Fontaine, 2025) 

Patients who benefit most

The latest and current literature points toward specific patient groups who may see real benefits from IS:

• Post-Covid patients

  
  

• Abdominal surgery patients

  
  

• High-Risk patients (e.g., COPD after thoracic surgery)

For these populations, IS can still be a useful part of a broader respiratory care strategy.

Patients who likely don't

• Healthy individuals recovering from low-risk surgeries

Research consistently shows that healthy patients recovering from low-risk surgeries derive little to no measurable benefit from incentive spirometry. (Kotta & Ali, 2020)

A Call to Action: 4 Steps to Take If Your Hospital Routinely Uses Incentive Spirometers

We're not just task doers or order followers. We are clinicians with insight, judgment, and the power to lead change. So if your hospital still sees routinely giving IS to all post-surgical patients as the norm, you can consider the following:

Step 1. Assess Your Hospital's Current Practice

• Is your team handing them out to every post-op patient?

• Find the cost per incentive spirometer

• Determine the monthly volume of administrations

• Evaluate the cost of nursing and respiratory therapists

• Review the ordering process and the supplier

Step 2. Utilize Internal Resources

Connect with your hospital's librarian or Nurse Scientist. They can guide you to the most recent and credible IS research. When the time is right, you can coordinate with your unit leaders and nurse educators for implementation.

Step 3. Share Evidence with Colleagues

Sharing this new information you learned with your coworkers may spark a gathered interest in promoting change at the unit level. You can attempt to tackle this yourself, but it may take a while to gather all the evidence-based literature on your own. As a team, putting together a meaningful presentation for your superiors can facilitate positive changes in your unit. Remember, there is power in numbers.

Step 4. Lead a Quality Improvement Project 

A quality improvement project presenting the latest evidence can show your hospital leaders the financial impact that focused versus blanket IS protocols can have at the unit and hospital level. Your team can also show how this change may improve nursing workload efficiency, streamlining workflows, leaving room for meaningful evidence-based interventions. Just to clarify, this isn't about withholding care or just trying to make it easier for the nurses. It's about delivering efficient, cost-effective, evidence-based care.

Conclusion: Letting Evidence Lead

As nurses on the frontlines, we have a responsibility to balance tradition with transformation. In a time where every dollar and every clinical minute counts, the best thing we can do is be curious. Be curious about every intervention we deliver, especially those we’ve never thought to question. The incentive spirometer may not be useless. But its universal use? That's certainly questionable. Let's stop doing things because we always have, and start doing things because they work.

References

Ababneh, Q. M., Abdelrahman, H., & Abdelhameed, M. E. (2025). Effectiveness of Incentive Spirometry Versus Deep Breathing Exercises in Preventing Postoperative Pulmonary Complications After Abdominal Surgery: A Comprehensive Review [Review of Effectiveness of Incentive Spirometry Versus Deep Breathing Exercises in Preventing Postoperative Pulmonary Complications After Abdominal Surgery: A Comprehensive Review]. Cureus. Cureus, Inc. https://doi.org/10.7759/cureus.80149

Casiraghi, M., Orlandi, R., Bertolaccini, L., Mazzella, A., Girelli, L., Diotti, C., Caffarena, G., Zanardi, S., Baggi, F., Petrella, F., Maisonneuve, P., & Spaggiari, L. (2024). The Role of Incentive Spirometry in Enhanced Recovery After Lung Cancer Resection: A Propensity Score-Matched Study. Journal of Clinical Medicine, 14(1), 100. https://doi.org/10.3390/jcm14010100

Chen, Y. Y., & Hsieh, Y.-S. (2024). A Narrative Review of Impact of Incentive Spirometer Respiratory Training in Long COVID [Review of A Narrative Review of Impact of Incentive Spirometer Respiratory Training in Long COVID]. International Journal of General Medicine, 5233. Dove Medical Press. https://doi.org/10.2147/ijgm.s492772

Cipriani, A., Furukawa, T. A., & Barbui, C. (2011). what-is-a-cochrane-review.pdf.

do Nascimento Junior, P., Módolo, N., Andrade, S., Guimarães, M., Braz, L., & El Dib, R. (2014). Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery (Review).

Eltorai, A. E. M., Baird, G. L., Pangborn, J., Eltorai, A. S., Antoci, V., Paquette, K., Connors, K., Barbaria, J., Smeals, K. J., Riley, B., Patel, S. A., Agarwal, S., Healey, T. T., Ventetuolo, C. E., Sellke, F. W., & Daniels, A. H. (2018). Financial Impact of Incentive Spirometry. INQUIRY The Journal of Health Care Organization Provision and Financing, 55. https://doi.org/10.1177/0046958018794993

Fontaine, B. L. Jr. (2025). The Impact of Tariffs on Occupational and Product Health and Safety. https://www.ishn.com/articles/114622-the-impact-of-tariffs-on-occupational-and-product-health-and-safety

Kotta, P. A., & Ali, J. M. (2020). Incentive Spirometry for Prevention of Postoperative Pulmonary Complications After Thoracic Surgery [Review of Incentive Spirometry for Prevention of Postoperative Pulmonary Complications After Thoracic Surgery]. Respiratory Care, 66(2), 327. American Association for Respiratory Care. https://doi.org/10.4187/respcare.07972

Larsen, T., Chuang, K., Patel, S., & Betancourt, J. (2022). Things We Do for No Reason™: Routine use of postoperative incentive spirometry to reduce postoperative pulmonary complications. Journal of Hospital Medicine, 17, 1010. https://doi.org/https://doi.org/10.1002/jhm.12898

Riggs, K. R., & Ubel, P. A. (2014). The Role of Professional Societies in Limiting Indication Creep [Review of The Role of Professional Societies in Limiting Indication Creep]. Journal of General Internal Medicine, 30(2), 249. Springer Science+Business Media. https://doi.org/10.1007/s11606-014-2980-0

Silva, H. V. C., Lunardi, A. C., Pinto, A. C. P. N., Macedo, J. R. F. F. de, & Santos, E. da C. dos. (2024). Is Incentive Spirometry Superior to Standard Care in Postoperative Cardiac Surgery on Clinical Outcomes and Length of Hospital and Intensive Care Unit Stay? A Systematic Review with Meta-Analysis [Review of Is Incentive Spirometry Superior to Standard Care in Postoperative Cardiac Surgery on Clinical Outcomes and Length of Hospital and Intensive Care Unit Stay? A Systematic Review with Meta-Analysis]. Brazilian Journal of Cardiovascular Surgery, 39(3). Brazilian Society of Cardiovascular Surgery. https://doi.org/10.21470/1678-9741-2022-0319

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