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Three Part Question

In [adult patients with rib fracture/s] does [incentive spirometry] [reduce the risk of complications]

Clinical Scenario

A 68-year-old man presents to the emergency department after sustaining blunt trauma to his chest after a fall. Imaging confirms two rib fractures with no other associated injuries. He is discharged home with analgesia and written advice. You wonder whether the use of incentive spirometry (IS) after discharge could reduce the risk of subsequent pulmonary complications.

Search Strategy

Embase 1974 to May 2025 and MEDLINE 1946 to May 2025 databases were searched using the Ovid Interface and the following search strategy: (Exp Rib Fractures/ OR rib fracture.mp) AND (Exp Spirometry/ OR incentive spirometry.mp) AND (Exp Treatment Outcome/ OR complications.mp)

Search Outcome

62 unique papers of which 3 included data on patients relevant to the clinical question (all in English).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Batomen Kuimi et al1 2019 Canada	439 patients who sustained at least one rib fracture and were discharged from the emergency department	Sub-study of a prospective observational cohort study	Primary Outcome Measures-Development of haemothorax, atelectasis and pneumonia within 14 days of the ED attendance	• Relative risk of haemothorax in spirometry group 1.63 (95% CI 1.15–2.3) • Relative risk of haemothorax in matched group 1.03 (95% CI 0.66–1.61) • Relative risk of atelectasis/ pneumonia in spirometry group 1.63 (95% CI 1.15–2.3) • Relative risk of atelectasis/pneumonia in matched group 1.07 (95% CI 0.68-1.72)	Prescription of IS left to treating physician. No randomisation of treatment arms Patient adherence to the IS treatment was not monitored Plain films were used to diagnose pulmonary complications. A new pleural effusion was assumed to be a haemothorax, potentially overestimating this complication No matching of 32% of the IS cohort
Dote et al2 2020 Japan	299 adult patients who had sustained rib fractures following chest trauma who received IS as an inpatient (group split in to early IS and late IS). Early IS was defined as started within 3 days of hospitalization or within 3 days of withdrawal of mechanical ventilation	Retrospective Observational Study	Primary Outcome Measures-Pulmonary complication rate (defined as pulmonary infection or respiratory failure requiring the escalation of oxygen therapy) occurring after the fourth day of hospitalization, or at the end of mechanical ventilation if the mechanical ventilation was started within 24 hours of admission	• Pulmonary complications-Adjusted odds ratio 0.71 (0.24–2.16) p-value 0.6 • Pulmonary infection-Adjusted odds ratio 0.76 (0.23–2.47) p-value 0.6 • Escalation of oxygen therapy 0.33 (0.03–3.53) p-value 0.4	No assessment of adherence to IS No standard protocol of IS treatment Retrospective study Patients allocated to early IS had statistically higher injury severity scores, rates of invasive ventilation and respiratory physiotherapy Treatment allocation based on individual physician’s practice Underpowered due to small sample size
Sum et al3 2019 China	50 patients who were admitted with traumatic rib fractures	Randomised controlled trial	Primary Outcome Measures-Pulmonary complication rate (including atelectasis, pneumonia, haemothorax and pneumothorax) assessed via a plain film of the chest on day 1 and 5 of admission, and pulmonary function tests on day 2 and 7 of admission	• Pulmonary complications occurred in 80.7% of the control group and 29.2% of the study group (p value .001) • Pneumothorax occurred in 3.8% of the control group and 0% of the study group (p value .0332) • Haemothorax occurred in 69.2% of the control group and 29.2% of the study group (p value .005) • Pneumonia did not occur in either group • Atelectasis occurred in 7.7% of the control group and 0% of the study group (p value .166) • Pulmonary functions test results showed decreased forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) in the control group. Comparing pre- and posttreatment FVC and FEV1, the IS group had significantly greater improvements (p < 0.001)	Small sample size with no power calculation Follow up limited to one week of injury so delayed complications potentially missed No blinding of participants (although difficult to blind given nature of intervention) Not clear if the radiologists reporting the chest plain films or pulmonologists conducting the lung function tests were blinded to treatment group

Comment(s)

Incentive spirometry (IS) is a breathing technique characterised by deep breathing performed through a device providing visual feedback4. It is one of the most commonly utilised methods for promoting pulmonary hygiene, and is frequently used in the postoperative setting to reduce the incidence of pulmonary complications by re-inflating atelectatic lungs5. This review examines whether there is evidence for its use as a treatment modality to reduce complications following rib fractures. The study by Batomen Kuimi et al is the only study that specifically investigates the use of IS after discharge from the ED. It did not show any evidence that unsupervised IS reduces the rate of complications when followed up at 7- and 14-days post discharge. However, the study had several limitations including lack of supervision and instruction limited to a five-minute teaching session with no standardised regime. The other two studies were conducted on patients who were admitted and underwent supervised IS. The study by Dote et al did not show any significant difference in benefit of IS in preventing complications after four days, however there was no defined IS regime in patients assessed. The study by Sum et al implemented a defined IS regime, and showed benefit when assessed via a plain film of the chest on day 1 and 5 of the patient’s admission. This study’s findings are limited due to the small sample size and lack of a power calculation, limiting the generalisability and reliability of their findings. In summary, to date, there is not enough evidence to support the routine use of IS to reduce complications after sustaining rib fractures. To answer the clinical question, a prospective study with a defined protocol of IS administration would be needed to establish if it has clinical utility in this setting.

Clinical Bottom Line

In summary, there is currently insufficient evidence to support the routine use of IS to reduce complications after sustaining rib fractures. References 1. Batomen Kuimi BL, Lague A, Boucher V, Guimont C, Chauny JM, Shields JF, Vanier L, Plourde M, Émond M. Potential benefits of incentive spirometry following a rib fracture: a propensity score analysis. CJEM. 2019 Jul;21(4):464-467. doi: 10.1017/cem.2018.492. Epub 2019 Feb 12. PMID: 30744728. 2. Dote H, Homma Y, Sakuraya M, Funakoshi H, Tanaka S, Atsumi T. Incentive spirometry to prevent pulmonary complications after chest trauma: a retrospective observational study. Acute Med Surg. 2020 Dec 31;7(1):e619. doi: 10.1002/ams2.619. PMID: 33408872; PMCID: PMC7775185. 3. Sum SK, Peng YC, Yin SY, Huang PF, Wang YC, Chen TP, Tung HH, Yeh CH. Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: a randomized controlled trial. Trials. 2019 Dec 30;20(1):797. doi: 10.1186/s13063-019-3943-x. PMID: 31888765; PMCID: PMC6937666. 4. Agostini P, Naidu B, Cieslik H, Steyn R, Rajesh PB, Bishay E, Kalkat MS, Singh S. Effectiveness of incentive spirometry in patients following thoracotomy and lung resection including those at high risk for developing pulmonary complications. Thorax. 2013 Jun;68(6):580-5. doi: 10.1136/thoraxjnl-2012-202785. Epub 2013 Feb 21. PMID: 23429831. 5. Martin TJ, Eltorai AS, Dunn R, Varone A, Joyce MF, Kheirbek T, Adams C Jr, Daniels AH, Eltorai AEM. Clinical management of rib fractures and methods for prevention of pulmonary complications: A review. Injury. 2019 Jun;50(6):1159-1165. doi: 10.1016/j.injury.2019.04.020. Epub 2019 Apr 22. PMID: 31047683.

References

1. Batomen Kuimi BL, Lague A, Boucher V, Guimont C, Chauny JM, Shields JF, Vanier L, Plourde M, Émond M. Potential benefits of incentive spirometry following a rib fracture: a propensity score analysi
2. Dote H, Homma Y, Sakuraya M, Funakoshi H, Tanaka S, Atsumi T. Incentive spirometry to prevent pulmonary complications after chest trauma: a retrospective observational study
3. Sum SK, Peng YC, Yin SY, Huang PF, Wang YC, Chen TP, Tung HH, Yeh CH. Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: a randomized controlled