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Incentive spirometry for children with sickle cell disorder

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VOL: 101, ISSUE: 42, PAGE NO: 55

Geok-Liew Ong, BSc, RGN, RSCN, is preceptorship facilitator for children's services, Royal London Hospital, London

Geok-Liew Ong outlines a study involving the use of incentive spirometry in a group of 20 paediatric patients with sickle cell disorder in an acute in-patient paediatric setting. The study was designed to assess the effectiveness of incentive spirometry in reducing the incidence of chest complications among these patients.

Geok-Liew Ong outlines a study involving the use of incentive spirometry in a group of 20 paediatric patients with sickle cell disorder in an acute in-patient paediatric setting. The study was designed to assess the effectiveness of incentive spirometry in reducing the incidence of chest complications among these patients.

Incentive spirometry is used to encourage deep breathing exercises and measures the inspiratory capacity of the lungs (Bellet et al, 1995); (Fig 1; Fig 2). It has been demonstrated that regular use of the technique improves respiratory muscle performance, stimulates the normal pattern of lung inflation and maintains patency of the airway (Respiratory Care, 1991).

Sickle cell disorder
It is estimated that 12,000 people in England have sickle cell disorder (Streetly et al, 1997). This is an inherited disorder of the haemoglobin which, under certain conditions, such as cold and hypoxia, causes the red blood cells to sickle (become crescent-shaped) (Fig 3). Aggregation of the red sickle-shaped cells causes micro infarcts (vaso-occlusion) in the peripheral circulation and certain organs, for example, the spleen, resulting in pain and anaemia (Hoffman et al, 2000). The sickled cells are fragile and have a short lifespan.

Further problems associated with sickle cell disorder include damage to vital organs, overwhelming infection and acute chest syndrome.

Acute chest syndrome occurs when red blood cells sickle and stick together in the blood vessels of the lungs (Bellet et al, 1995). In so doing they block the flow of blood in the alveoli and prevent gaseous exchange of oxygen and carbon dioxide, which leads to hypoxia and increased risk of chest infection.

Acute chest syndrome is the primary cause of complications in sickle cell disorder and the second most likely reason for admission to hospital (Bellet et al, 1995; Vichinsky et al, 2000; Yale et al, 2000). It is characterised by 'pleuritic' chest pain, fever, hypoxia, cough and dyspnoea. Usually there is a rapid decrease in haemoglobin, with increased platelets and white blood cells.

Reasons for initiating a study on the benefits of incentive spirometry
Opioid analgesia is routinely used for managing pain associated with sickle cell disorder, but this can result in shallow breathing and hypoventilation (Bellet et al, 1995). The latter predisposes the patient to developing chest infections, and exacerbates hypoxia. However, a number of reviews have highlighted the benefits of using incentive spirometry to reduce chest syndrome because it encourages deep inspiratory effort and prevents hypoxia (Bellet et al, 1995; Yale et al, 2000). On this basis, a trial was carried out to assess the benefits of incentive spirometry for patients with sickle cell disorder who had pulmonary complications.

A further reason for investigating the effectiveness of the technique was that it could provide an alternative method of facilitating breathing exercises for patients with sickle cell disorder when the physiotherapy services are limited, such as at evenings and weekends. If it proved beneficial, nurses would be able to help the children at these times.

Aim of the study
The main aim of the study was to explore whether incentive spirometry would reduce the incidence of acute pulmonary complications in children with sickle cell disorder who were admitted to hospital with a painful crisis.

A working group was formed, consisting of the haematology consultant, the haematology registrar, clinical nurse specialists for haematology, physiotherapists, the ward play specialist, the ward administrator, the ward sister, and a preceptorship facilitator. It was decided to replicate a study by Bellet et al (1995), which indicated that incentive spirometry could reduce acute chest syndrome and pulmonary complications in children with sickle cell disorder.

Selection criteria for inclusion, and the methodology, were agreed by the working group, as were the documentation, audit forms, and questionnaires that would be required. The financial cost was discussed with the ward sister and the finance manager. The group also liaised with the facilities department to ensure that a supply of incentive spirometers would be delivered before the start of the trial.

Twenty children between eight and 16 years of age with sickle cell disorder who were admitted with episodes of acute chest or back pain above the diaphragm were included in the study, which ran from May 1, 2002, to August 31, 2002.

Each patient in the study took 10 maximal inspirations using an incentive spirometer every two hours between 8am and 8pm until his/her chest pain or back pain subsided. The nurse recorded on a documentation sheet the highest reading on the incentive spirometer, together with the patient's pain score and vital signs each time the incentive spirometer was used (Table 1).

Play therapy was used in the incentive spirometry sessions.

Children from the age of eight were included in the study because the working group believed that, by this age, the children would be able to understand the instructions for using the spirometer. Since the trial, we have found that children as young as five years have been able to use the device.

Training
Senior physiotherapists trained the qualified nurses to use the incentive spirometers, and the sessions were reinforced by a training video. The physiotherapists also assessed the patients' ability to use the spirometer to ensure that the correct technique would be used during the study. Box 1 outlines the procedure for helping a patient use the device.

Barriers to Implementation
As each spirometer costs approximately £10, there were financial implications of introducing this single-use item routinely. However, there would be potential savings, in that the length of time a child stayed in hospital would be reduced.

Some nurses were concerned that the project would increase their workload. To overcome their fears, the project team held regular meetings with all those nurses who would be involved, where the benefits that incentive spirometry would have for their patients were emphasised.

Evaluation
The patients were given a questionnaire asking them to evaluate certain aspects of using the spirometer. Overall, 42 per cent found that it was easy to use; 58 per cent found it difficult initially, but easier with practice. The children were also asked whether using the device eased their pain - 75 per cent said using the spirometer did reduce their pain, and that using it made taking a deep breath easier.

An audit of the documentation from the 20 children included in the study indicated that after they had used the incentive spirometer there was no incidence of chest crisis or complication. Furthermore, it was observed that the children's condition improved clinically and that there were improvements in their oxygen saturation levels. In addition, children with sickle cell disorder were able to carry out incentive spirometry sessions even though they were taking opiate analgesia. The audit also showed that deep breathing exercises were carried out without a physiotherapist being present.

Conclusion
Incentive spirometry is now used in our in-patient services for children with sickle cell disorder, and the nurses have incorporated patient education and support into the patient care plans. Play therapy facilitates the children's cooperation.

The working group believes that the inexpensive intervention of incentive spirometry has a role to play in reducing chest complications in children with sickle cell disorder who are hospitalised with a painful sickle cell crisis.

POINTS FOR REFLECTION
- What is incentive spirometry?

- What are the benefits of incentive spirometry in the management of children with a sickle cell crisis?

- How could you encourage a child to use incentive spirometry?

USEFUL WEBSITE
www.sicklecellsociety.org

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