Review Article

Volume 13:1, 2023 Journal of Pulmonary & Respiratory Medicine

ISSN: 2161-105X Open Access

Incentive Spirometer and Respiratory Muscle Training

Devices: What Do Physiotherapists Need to Know?
Dipti Kadu*
Department of Physiotherapy, Seth G.S. Medical College, Mumbai, Maharashtra, India

Abstract

Physiotherapy plays a crucial role in pre-habilitation, post-operative care, and rehabilitation to reduce postoperative pulmonary
complications. The use of various devices like incentive spirometers, and respiratory muscle training devices is an integral part of chest
physiotherapy. Currently, there are many devices available in the market, which have been used in physiotherapy. Despite their regular use
in the clinical setup, many clinical practitioners do not have thorough knowledge about their functioning and effect. This article intends to
make physiotherapists aware of the types, components, teaching techniques, and uses of such devices, to have optimal and specific
benefits. The knowledge of these devices may help professionals to select the best device to be used. To select the most appropriate one, it
is also necessary to consider the specific health condition, the nature of the impairments, the purpose of the training, and whether its use
is within a research or clinical context.

Keywords: Incentive spirometer • Volume targeted spirometer • Flow targeted spirometer • Respiratory muscle training devices

Introduction Incentive spirometer

As per the recent data, the incidence of Postoperative Pulmonary An incentive spirometer is considered one of the commonly used
Complications (PPCs) in major surgery ranges from <1% to 23%. adjuncts indicated in pulmonary rehabilitation. It is a mechanical
Many studies have shown that pulmonary complications are more device, which works on the principle of Sustained Maximal
common than cardiac complications during the post-operative period. Inspiration (SMI), by encouraging the patient to take long, slow, deep
According to the European joint task force PPC includes respiratory breaths using visual feedback and indicated to improve the
infection, respiratory failure, pleural effusion, atelectasis, respiratory capacity of the user [5].
pneumothorax, bronchospasm, aspiration pneumonitis, pneumonia,
Acute Respiratory Distress Syndrome (ARDS), pulmonary embolus, The objective of the incentive spirometer usage is to, enhance
etc. Post-operative respiratory failure is the most common among inspiratory muscle performance, simulate the normal pattern of
them [1]. Physiotherapy plays a crucial role in preventing and treating pulmonary hyperinflation, and increase trans-pulmonary pressure and
PPCs through pre-habilitation, post-operative therapy, and inspiratory volumes. Long, slow, deep breaths, decrease
rehabilitation [2,3]. Chest physiotherapy, Deep Breathing Exercises pleural pressure and promote lung expansion and better gas
(DBE), Postural Drainage (PD), Active Cycle Breathing Technique exchange [6]. It also improves ventilation/perfusion mismatch and
(ACBT), Incentive Spirometry (IS), and Respiratory Muscle Training alveolar PaO2 gradient, which is suggestive of improved
(RMT) are components of physiotherapy [3,4]. RMT has growing alveolar ventilation and subsequent reduction in the
evidence about its efficacy and effectiveness. Although incentive intrapulmonary shunt. It helps to maintain PaO2 levels near
spirometry is widely used clinically as a part of a routine prophylactic normal when sustained maximal inspirations are repeated every
and therapeutic regimen in pre-operative and post-operative hour. When the procedure is repeated daily, atelectasis is prevented
respiratory therapy, its clinical efficacy remains controversial due to or reversed [7].
inadequate evidence. Despite their regular use in the clinical setup, Indications
many clinical practitioners do not have thorough knowledge about the
functioning and effect of these devices. To the best of our knowledge, • Presence of pulmonary atelectasis or conditions predisposing
such an informative article is not available; this made us focus on this to the development of pulmonary atelectasis like upper-
area. This article intends to make physiotherapists aware of the abdominal, thoracic, cardiac, or lower-abdominal surgery,
types, components, teaching techniques, and uses of the various
types of devices.

*Address for Correspondence:

Dipti Kadu, Department of Physiotherapy, Seth G.S. Medical College, Mumbai, Maharashtra, India, Tel: 9869428443;
E-mail: kadu_dipti@yahoo.com
Copyright: © 2023 Kadu D. This is an open-access article distributed under the terms of the creative commons attribution license which permits unrestricted
use, distribution and reproduction in any medium, provided the original author and source are credited.
Received: 24 December, 2022, Manuscript No. JPRM-22-84624; Editor assigned: 27 December, 2022, PreQC No. JPRM-22-84624 (PQ); Reviewed: 10 January, 2023,
QC No. JPRM-22-84624; Revised: 24 March, 2023, Manuscript No. JPRM-22-84624 (R); Published: 31 March, 2023, DOI: 10.37421/2161-105X.2023.13.620
Kadu D J Pulm Respir Med, Volume 13:1, 2023

prolonged bed rest, surgery in patients with COPD.

• Obstructive conditions like COPD, and bronchial asthma to
strengthen respiratory muscles.
• Extra-pulmonary restrictive impairments related to a dysfunction
of the diaphragm or other respiratory muscles like in patients with
neuromuscular disease or spinal cord injury.
• Pulmonary restrictive impairments like ILD to improve lung
volumes or strengthen respiratory muscles.
• To strengthen the inspiratory/ expiratory muscles in patients on Figure 1. Pediatric spirometer.
mandatory ventilation to assist in successful weaning from the
ventilator.

Contraindications
• Patients who can't be instructed or supervised to assure the
appropriate use of the device.
• Non-cooperative or non-comprehensive patients.
• Very young patients (four years or younger) and others with
developmental delays.
• Patients who are confused or delirious.
• Patients who are heavily sedated or comatose.
• Patients unable to take a deep breathe effectively due to pain, Figure 2. Adult spirometer.
diaphragmatic dysfunction, or opiate analgesia.
Parts of the spirometer: This incentive spirometer is made up of a
• Patients with moderate to severe COPD and acute asthma have
mouthpiece, a flexible corrugated breathing tube, an air chamber,
an increased respiratory rate and hyperinflation.
and an indicator (either piston or ball). The breathing tube
is connected to the air chamber and encompasses a mouthpiece at
Hazards and complications the opposite end. The indicator is found inside the air chamber. A
• Barotrauma (emphysematous lungs). few models also have a slider, which can be moved manually to set
• Hyperventilation. the target [10].
• Discomfort secondary to inadequate pain control. Target: In the case of the volume targeted spirometer, the patient
• Hypoxia secondary to interruption of prescribed oxygen therapy aims to attain a preset target volume. The patient is instructed to
if face ma ask or shield is being used. reach a volume goal that is dependent on their height and age. The
• Exacerbation of bronchospasm. patient receives visual feedback from the piston rising to
• Fatigue. the predetermined level. The patient is instructed to hold his breath
for at least 2-3 seconds at full inspiration [11]. These devices
Types encourage slow and controlled inhalation while maintaining a disc
Various types of incentive spirometers are commercially available. at the target volume i.e. end-inspiratory hold and flow marker at the
optimal level. Patient is instructed to inhale within an ‘ideal’ flow rate
Depending on their working mechanism, they are either by keeping the flow indicator within the prescribed range and
volume targeted or flow targeted [8]. inhaling as deeply as possible at the same time.
Mechanism: Volume targeted devices not only impose less work
Literature Review of breathing but also improve diaphragmatic activity. In a
recent study, it was observed that volume incentive spirometry has
Volume targeted spirometer: This type of device has a chamber, resulted in early recovery of both pulmonary function and
which has volume measurements displayed on it. A piston within the diaphragm movement in patients who had undergone laparoscopic
chamber rises when the patient inhales air from the spirometer. Due abdominal surgery [12].
to less work of breathing, this type of device is preferred [9]. This type
Flow-targeted incentive spirometer: These spirometers have
of incentive spirometer provides appropriate feedback about the
been popularly used in postoperative conditions as adequate
volume inhaled during slow sustained inspiration. Pediatric (Figure 1)
inspiratory flows are required for airway clearance techniques
and adult (Figure 2) variants of this type are available.
like huffing and coughing. Thus they assist in airway
clearance by improving inspiratory flows. These flow-targeted
devices set the target of desired flow. Variants of the flow-
targeted incentive spirometer like a triple ball (Triflow), single
ball, and pediatric are available.

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Triflow
can sustain the minimum inspiratory effort required for
Triflow (Figure 3) encompasses three interconnected columns effective therapy.
within which lightweight plastic floats are seated. Each column
has printed on the outside of the column the least amount of flow
needed to raise the ball. With an airflow rate of 600 to 1200 ml/
second, deep breath lifts the balls. When all three balls reach
the top of the spirometer, the patient has achieved a flow speed of
1200 ml/second. The number of balls and also the level to which they
rise depends on the magnitude of the flow achieved. At lower flows,
depending on the magnitude of the flow the first ball rises. As
the inspiratory flow increases, the second ball rises, followed by the
third ball [13].

Figure 5. Pediatric flow targeted incentive spirometer.

There are many other flow targeted devices, which work on a
similar principle.
Target: In a flow targeted incentive spirometer, the patient tries to
generate a predetermined flow. The patient is encouraged to
maintain an end-inspiratory hold for 2-3 seconds [14]. In the triflow
device, two out of three plastic balls should be raised and
sustained for 2-3 seconds. The third ball indicates high flow and
turbulence as well as acts as a control; hence it should not be
Figure 3. Triflow. raised. The patient is instructed to take a deep breath in such a
Single ball flow-targeted incentive spirometer: A breathing tube is way that, the ball stays at the highest for as long as possible. Some
connected to a closed chamber (Figure 4). A full closure of this units might offer different flow rates; the therapist can change the
chamber allows the ball to rise easily at a 200 cc/sec inspiratory flow flow rate to provide different levels of challenge.
rate. A target flow can be set on the top dial by rotating the dial. The Mechanism: The patient attempts to raise the floats through
ball in the chamber does not rise unless the targeted flow is achieved inspiratory flow created by negative intra-thoracic pressure,
by the patient. either with a quick or sustained deep breath. The slow
sustained inspirations are emphasized, as they are more
effective for lung expansion instead of fast inspirations. Slow
inspiration improves collateral ventilation and reduces patient
discomfort when performing post-operative breathing exercises.
Apart from this, flow-targeted devices impose more work of
breathing and increase the muscular activity of the upper chest [15].
How to use incentive spirometers?
Clear and precise instructions should be given along with a
demonstration using a dedicated device.
Patient’s position: The patient should be relaxed and in an
upright sitting (Figure 6) or standing position, preferably on a chair or
either side-lying position depending upon the affected area, which is
to be targeted for the expansion.
Position of the incentive spirometer: The incentive spirometer
has to be positioned upright, at the level of the eyes to see accurate
Figure 4. Single ball flow-targeted incentive spirometer. volume and flow. The tubing should be straight to reduce the
resistance. The patient should hold the spirometer handle with one
Pediatric flow targeted incentive spirometer: This variant (Figure
hand and the mouthpiece in the mouth with the opposite hand, with
5) is specifically useful in pediatric, geriatric, or weakened patients
lips sealed around the mouthpiece firmly.
with flow settings from 100 ml/sec to 600 ml/sec, virtually any patient

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• Ten breaths every one to two hours while awake.

• Ten breaths, 5 times a day.
• Fifteen breaths every 4 hours.
After proper instruction and demonstration, the patient should
be encouraged to perform incentive spirometry independently.
Maintenance of incentive spirometer: To maintain hygiene and
prevent the entry of dust or foreign objects into the tubing the device
Figure 6. Positioning of patient and spirometer. should be kept covered, when not in use. To prevent cross-infection,
the use of the device should be restricted to one person only.
Technique: The patient should be trained pre-operatively to
Patients should be advised to disconnect the mouthpiece from the
facilitate learning. Post-operative pain may make learning a
new technique difficult. tubing and clean it with water, dry it, and re-attached it after every
use [18].
While doing inspiratory exercise with volume as well as a
flow targeted spirometer, the patient is instructed to blow out Selection of incentive spirometer: There is a difference in the
first completely through the mouth i.e. exhale to Functional mechanism of volume and flow-targeted incentive spirometer. A
Residual Capacity (FRC) followed by a slow deep breath comparison of both types of incentive spirometers suggested that
through the mouthpiece. The patient is advised to achieve the target there is a physiological difference in the effect of these two
and maintain an end-inspiratory hold without suffocation. In the case devices. Flow targeted devices impose more work on breathing and
of the volume-targeted spirometer, the flow indicator should be increase the muscular activity of the upper chest. Volume
maintained within the optimal flow limit, as marked over the incentive targeted devices impose less work on breathing, encourage
spirometer [16]. larger inspiratory lung volume, and improve diaphragmatic
Expiratory exercises can be performed with the same device by activity compare to a flow-targeted spirometer. In a recent study,
holding it upside down. While doing the expiratory exercise it was observed that volume-targeted incentive spirometry has
the patient is instructed to take a deep breath through the nose resulted in early recovery of both pulmonary function and
followed by exhalation through the mouth into the mouthpiece. In the diaphragm movement in patients who have undergone laparoscopic
case of a volume targeted incentive spirometer, the patient is advised abdominal surgery. A randomized controlled trial by Amaravadi
to lift the piston as much as possible without raising the flow Sampath Kumar et al. found that flow and volume targeted incentive
indicator.
spirometry had demonstrable and comparative improvements in
Breathing pattern should be maintained at the same time pulmonary function and exercise tolerance and can be safely
expansion of the lower chest should be emphasized for better results. recommended to patients undergoing open abdominal surgery as
Monitoring: Throughout the procedure, the patient observes the there were no adverse events recorded [19].
spirometer while the physiotherapist monitors the patient's Special consideration: The presence of an open tracheal stoma
breathing pattern and technique learned. Direct supervision is not or tracheostomy is not a contraindication but requires adaptation (like
necessary once the patient demonstrates mastery of the
a universal connector or connecting tubes) of the spirometer. Those
technique. However, intermittent reassessment of the lung
function and technique is essential to optimize the performance. on oxygen can use a nasal cannula or an incentive spirometer that
entrains oxygen. Even patients on a spontaneous mode of the
Monitoring the breathing pattern while using the volume as well as ventilator can be trained with an incentive spirometer intermittently, if
a flow targeted incentive spirometer, is important and should hemodynamically stable.
be communicated to the patient. Studies have shown that
slow sustained inspiration used in volumetric incentive Evidence: The systematic review and meta-analysis done by
spirometry effectively promotes lung expansion rather than fast Kerrie Sullivan et al. showed that the incentive spirometer alone
inspiration. The expansion of the lower chest should be is less likely to result in a reduction in the number of adult patients
emphasized rather than the use of the accessory muscles of with PPCs, in mortality, in the hospital stay, following cardiac,
inspiration which would encourage the expansion of the upper thoracic, and upper abdominal surgery. Other systematic reviews
chest. Diaphragmatic movement is thought to be an important also uphold this conclusion, by not supporting the use of incentive
factor in the prevention of postoperative pulmonary complications
spirometers for decreasing the incidence of PPCs following
[17].
cardiac or upper abdominal surgery. Paulo Nascimento et al.,
found no statistically significant differences between the
Protocol
participants receiving incentive spirometer compared to those
Several authors suggest using the device 5-10 breaths per receiving deep breathing exercises, and chest physiotherapy in
session, at a minimum, every hour while awake which amounts to the risk of developing a pulmonary condition or the type of
100 times a day. The caregiver does not need to be present with complication. There was no evidence that an incentive spirometer
each performance, and the patient should be encouraged to perform is effective in the prevention of pulmonary complications.
spirometer exercises independently.
Although these systematic reviews, meta-analyses, and reviews
There is a lack of evidence for a specific frequency for use of
incentive spirometers; few clinical trials suggest the following have concluded that, the incentive spirometer is not much effective; it
protocols: remains widely used without standardization in clinical practice as
there is low-quality evidence regarding the lack of effectiveness of
incentive spirometer for the prevention of PPCs in post-operative

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patients. The review by Nascimento et al., underlines the urgent need Thus, when their fibers are overloaded, the respiratory muscles
to conduct well-designed trials in this field. respond to training stimuli, by undergoing adaptations to their
Numerous studies support the use of the incentive spirometer in structure in the same manner, as any other skeletal muscles.
clinical practice to improve ventilation, and lung expansion, to Indications:
prevent and reduce PPCs like atelectasis. Incentive spirometer
facilitated a sustained deep breath. The same effect can be • Primary indications are dyspnea and/or exercise intolerance.
encouraged without the incentive spirometer but the use of the • Respiratory conditions (such as asthma, bronchitis, emphysema,
device often causes greater inhaled volume, a more and COPD), neuromuscular conditions (such as a cerebral-
controlled flow, and better compliance to practice as it gives vascular accident), or cardiac conditions.
visual feedback on the device. This visual feedback can be useful to
assess a patient's inspiratory effort by measuring the inhalation • Subgroup of post-operative or geriatric patients.
volume. It can be used in rehabilitation as a favorable tool, as it • Specific conditions where either IMT has been shown to produce
is cheaper and easy to manage with no known side effects. It some clinically significant benefits or there is a theoretical
is simple to train and does not require assistance once a rationale for IMT, based upon the presence of inspiratory muscle
patient has learned how to use it properly [20]. dysfunction, abnormal respiratory mechanics, producing
a demand/capacity imbalance within the respiratory pump.
The study by Amaravadi S Kumar et al. has shown that an
incentive spirometer might improve pulmonary functions, as • Some specific physiological indicators of potential load-capacity
it encourages patients to take long, slow, sustained deep imbalance of the respiratory muscles, and/or inadequate
inspirations, which leads to maximal inspiratory volume and assist to respiratory muscle function like reduced respiratory muscle
maintain the patency of the smaller airways. Postoperative strength, dyspnea, orthopnea, expiratory flow limitation,
hypoxemia is reduced by using an incentive spirometer which hyperinflation, reduced respiratory system compliance, elevated
provides low level resistance training to the diaphragm and ratio of dead space to tidal volume (VD/VT), tachypnea,
minimizes fatigue thereby improving inspiratory muscle strength hypoxemia, hypercapnia, poor cough function, inability to breathe
and enhancing lung inflation. Also, AACVPR guidelines support without the aid of mechanical ventilation.
the use of the incentive spirometer in the pulmonary rehabilitation • Sports training.
program.
• Individuals with Fontan physiology condition.
Respiratory Muscle Training (RMT) Devices: Respiratory
Muscle Training (RMT) can be defined as a technique that aims Contraindications: Although evidence of IMT related adverse events
to improve the function of the respiratory muscles through is not present, there is a theoretical risk of barotrauma-related
specific exercises and might help to reduce dyspnea on exertion. injuries. Accordingly, caution should be exercised in the following
RMT may consist of Inspiratory Muscle Training (IMT) situations:
Expiratory Muscle Training (EMT) or a combination of the two.
• A history of spontaneous pneumothorax.
The respiratory muscles are unique among the skeletal muscles
• A pneumothorax due to a traumatic injury that has not healed
since they must work without sustained rest throughout life. However,
fully.
respiratory and neurological conditions, electrolyte disturbances,
blood gas abnormalities, intense weight loss, and cardiac • A burst eardrum that has not healed fully, or any other condition
decompensation, may affect these muscles. Weakness of the of the eardrum.
respiratory muscles is defined as a reduction in muscle The sub-group of asthma patients with unstable asthma and
contractility, resulting in the inability of the respiratory muscles to abnormally low perception of dyspnea are also unsuitable candidates
generate normal levels of pressure and airflow during inspiration for IMT.
and expiration. The reduction in respiratory muscle strength could
compromise exercise performance. Thus, the implementation of Types: Respiratory Muscle Training (RMT) devices enhance
interventions, which have the potential to increase the strength of the respiratory muscle strength, endurance, and exercise capacity. It
respiratory muscles and, consequently, improve exercise is divided into two main categories Inspiratory Muscle Training
performance and functional capacity is indicated, since (IMT) devices and Expiratory Muscle Training (EMT) devices.
deconditioning is one of the most common preventable causes
of morbidity and mortality. Inspiratory Muscle Trainer (IMT)
RMT has the potential to improve the function of the respiratory
IMT devices improve both inspiratory and expiratory muscle
muscles, which consists of repetitive breathing exercises against
strength. They have two different modes, each for a specific use.
an external load. The protocols can be modified by the time,
intensity, and/or frequency of the training. However, to obtain
• Voluntary isocapnic hyperpnea, which enhances the inspiratory
a training response, the muscle fibers must be overloaded, by
requiring them to work for longer, at higher intensities, and/or muscle endurance.
more frequently, than they are accustomed to. To achieve adequate • Resistive inspiratory muscle training, which enhances the
overload most training regimens, combine two or three of these inspiratory muscle strength.
factors. Furthermore, the adaptations elicited by the training depend
This mode has two types.
upon the type of stimulus, to which the muscle is subjected. The
high-intensity and short-duration stimuli tend to improve strength, Pressure resistive IMT devices (PR-IMT): PR-IMT devices are
and the low-intensity and long-duration stimuli tend to improve the usually handheld devices that incorporate a spring-loaded one-way
endurance of the respiratory muscles. valve that is impeded with different intensities, which opens to permit

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airflow provided that a preset inspiratory pressure has been reached. PEP masks are often used as flow dependent inspiratory muscle
The load is independent of airflow and may be set at a percentage of trainers by attaching the resistance to the inspiratory port of the
Maximal Inspiratory Pressure (MIP). The intensities can be adjusted ventilator and can be used to prepare the patient for successful
by the resistive load knob varying from low to high. This encourages weaning by varying the expiratory pressures.
the patient to produce a set inspiratory force with every breath, which
Flow resistive devices have two types, passive and dynamic.
creates a training effect.
Passive flow resistive device: It requires inhaling through a fixed
In addition, the normal mechanism of PR-IMT devices requires the
orifice, which can be changed to increase the training load.
initiation of negative pressure created by the subjects to overcome
The smaller the diameter, the higher the load required to
the load resistance. The effectiveness of these devices has been
overcome. However, one of the disadvantages that the flow
proved by Turner et al. by stating that, the PR-IMT devices lead to an
resistive devices have is that they are affected by the inspiratory flow
improvement in Maximal Inspiratory Pressure (MIP), Maximal
which is initiated by the subject. Thus, breathing patterns should be
Expiratory Pressure (MEP), diaphragm mobility, and
monitored during training when using these devices.
thickness. Several types of PR-IMT have wide ranges of features
like muscle strengthening, endurance training, and Dynamic flow resistive device: It requires inhaling through a
improvement of the perception of dyspnea. Such devices can variable orifice (Figure 9) within the breath which makes the dynamic
be used with different intensities like high, moderate, and low flow resistive devices superior to passive devices.
(Figure 7).

Figure 9. Dynamic flow resistive device.

Figure 7. Pressure resistive IMT devices (PR-IMT). Expiratory Muscle Trainer (EMT): In contrast to IMT, EMT
devices (Figure 10) improve the strength of the expiratory muscles
This can be objectively documented by measuring the mean or only. Strengthening the expiratory muscles is important for
Maximum Inspiratory Pressure (MIP) using a maximum pressure effective airway clearance. The construct and principle of EMT
monitor device. A patient on a ventilator (Figure 8) can be devices are similar to IMT except that the person is supposed to
successfully weaned off if MIP reaches a level of more than 30 cm of exhale in the device instead of inhale as in IMT. A set pressure
water. by recoiling the spring ensures that the target expiratory pressures
are reached.

Figure 10. Expiratory muscle trainer.

How to use the RMT device?
Clear and precise instructions should be given along with a
demonstration using a dedicated device.

Figure 8. MIP and MEP measurements and inspiratory muscle

Discussion
training on a ventilator (spontaneous mode).
Patient position
Flow resistive IMT devices: A flow dependent device sets
The patient is advised to sit in a comfortable position and put
resistance by the inspiratory orifices of the various dimensions,
the nose clip so that all of the breathing is done through the mouth.
but this load may be lessened by the patient taking slow
Place the lips around the mouthpiece, making a good seal (Figure
breaths to reduce turbulence. These devices are less likely to
11). RMT can be done in intubated patients (Figure 12) through
provide a training effect but best are used for desensitization to
endotracheal or tracheostomy tubes by connecting the RMT
breathlessness. These devices provide resistance during expiration
device with flexible tubing.
similar to PEP masks.

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Device position Maintenance

For the spontaneously breathing patient, the mouthpiece is held in The maintenance of the RMT devices is similar to the
the mouth with lips tightly sealed around it to ensure no leak. incentive spirometer.
This device does not require the patient to see the device as there
is no visual feedback like in the spirometer. The flow of air is
Protocol
possible only if the set pressure target is achieved with expiratory
effort. For strength training, the target is generally 80% of MIP and for
endurance training, it is 60% of MIP, but benefits have been found at
30% of the maximum. The level of resistance should cause the
patient to become a little more breathless than usual without
becoming silent or disturbed if the goal is to desensitize patients
to breathlessness. The resistance should be adjusted such that
the patient can tolerate it for 10 minutes. Patients should be at ease
while inhaling strongly enough to overcome resistance. They should
work at different ranges to prevent muscle fatigue while avoiding
excess hyperinflation.
The duration of the training can be increased from about 5 minutes
twice a day to about 15 minutes three times a day, with
resistance increased fortnightly for the first 6 weeks and then
Figure 11. Patient using IMT Device. monthly.
When IMT fits into the patient's schedule and the resistance is
comfortable, adherence is reasonable. The principles of training such
as alternate exercise with rest, avoiding distressing levels of
fatigue (overtraining), and progress by increasing time and/or
resistance should be followed.

Special consideration
If oxygen is needed while RMT training, a nasal cannula can be
used.
Selection: IMT attempts to enhance respiratory muscle strength
and endurance. Inspiratory resistive training uses devices that
allow inhalation against resistance at a specific threshold. IMT
Figure 12. Inspiratory muscle training via endotracheal and may improve dyspnea and allow a patient to sustain a higher
tracheostomy. level of ventilation by favorably altering the ratio between the
current inspiratory pressure generated and the maximal inspiratory
Technique to use RMT device pressure (PI/PI max) and by reducing compromising dynamic
hyperinflation through a reduction in inspiratory time.
The patient is instructed to take a deep breath and then exhale
slowly at an inhalation to exhalation ratio of 1:3 or 1:4 (ensuring that Evidence
exhalation is longer than the inhalation time). These steps are
repeated until completing 30 breaths without the feeling of Although RCT in 25 patients with COPD found no advantage, pilot
dizziness by pausing in between for normal breaths as required. The research in 36 patients with COPD found that using IMT in
number of repetitions, load, training time, and resting time during the combination with an exercise program led to better improvement
session is noted. To ensure proper understanding the procedure is in walk test distance than those who underwent exercise alone. IMT
explained verbally and a booklet of the instruction is provided, if led to better improvement in cardiopulmonary exercise test
possible. parameters after an exercise program, according to another pilot trial
including 42 patients. Given their shortcomings in important areas,
Monitoring the results of this study seem to be susceptible to bias. These
results were not later repeated, in two RCTs with a minimal risk of
The procedure should be demonstrated by the therapist to the bias that evaluated IMT as a supplement to exercise programs, IMT is
patient and supervised till they learn. The breathing pattern is not advised due to the inconsistent results and significant
monitored during training while using these devices. Once limitations of the research taken into consideration.
the technique is mastered, patients can use this device by
themselves without supervision. To ensure adherence, a diary can be Although the British Thoracic Society 2013 guidelines do not
maintained or a daily reminder can be set. support the routine use of the IMT in pulmonary rehabilitation, there
is recent evidence that supports the use of the RMT in training. A
systematic review and meta-analysis done by Beaumont et al.
concluded that IMT using threshold devices improves inspiratory

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muscle strength, exercise capacity, and Quality of Life (QOL), Incentive spirometry alone is not recommended for routine use in
and decreases dyspnea. However, there is no added effect of the preoperative and postoperative setting to prevent postoperative
IMT on dyspnea during Pulmonary Rehabilitation (PR) compared pulmonary complications (1B).
with PR alone in COPD patients. The systematic review done
• It is recommended that incentive spirometry be used with deep
by Rocío Martín-Valero et al., examined levels of
breathing techniques, directed coughing, early mobilization,
evidence and recommendation grades of various therapeutic and optimal analgesia to prevent postoperative
interventions of IMT in people who have had a stroke. Benefits pulmonary complications (1A).
from varying degrees of resistance and force on the respiratory • It is suggested that deep breathing exercises provide the same
muscles are seen in this population. This review concluded that benefit as incentive spirometry in the preoperative
IMT is required to implement respiratory muscle training as a and postoperative setting to prevent postoperative complications
national health system service and to take into account its inclusion (2C).
in the traditional neurological program. According to Stefanie • Routine use of incentive spirometry to prevent atelectasis
Vorona et al. systematic review and meta-analysis, inspiratory in patients after upper abdominal surgery is not recommended
threshold loading has been used in the majority of trials using IMT (1B).
in critically sick patients. IMT is practical, well tolerated, and • Routine use of incentive spirometry to prevent atelectasis
improves both inspiratory and expiratory muscle strength in after coronary artery bypass graft surgery is not recommended
(1A).
critically ill patients. Future research will be necessary to confirm
• It is suggested that a volume-oriented device be selected as an
IMT's effect on clinical outcomes. incentive spirometry device (2B).
The case study was done on the 6 failure to wean patients and
has shown that the Inspiratory Strength Training (IST) sessions may References
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13. Beaumont, Marc, Patrice Forget, Francis Couturaud, and Gregory 18. de Menezes, Kenia Kiefer Parreiras, Lucas Rodrigues do
Reychler, et al. "Effects of inspiratory muscle training in COPD Nascimento, and Patrick Roberto Avelino, et al. "A review on
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17. Respiratory Muscle Training Devices: What Do Physiotherapists Need
“reference-based” to “evidence-based”." Respir Care 55 (2010): 787-788.
to Know?." J Pulm Respir Med 13 (2023): 620

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