Correspondence

Incentive Spirometry in Sickle Cell Crisis

N Engl J Med 1996; 334:124-125January 11, 1996

Article

To the Editor:

Bellet and associates (Sept. 14 issue)1 report their use of incentive spirometry in patients with painful crises due to sickle cell anemia. They show that patients in crisis had a high incidence of chest-wall involvement. Patients with thoracic bone involvement had a higher frequency of pulmonary complications. These complications were prevented by the use of incentive spirometry.

Although these data are of some interest, the last paragraph of the paper is sure to cause debate. The authors suggest that “this inexpensive intervention might prevent chronic lung disease.” This statement contains two speculative elements. First, the treatment is not inexpensive. The authors do not give figures for the cost, but the description of the method used suggests the presence of a therapist during all the treatments. Thus, the cost of this time must be considered. If the therapy were to be given unmonitored, a separate trial would be needed to assess the benefit. Second, the benefit of the treatment appears to be nil in real terms. There were fewer abnormal chest films among the patients treated with incentive spirometry, but the use of resources was similar in the treated and control groups. No financial or other benefit to the patient accrued. The concept that atelectasis leads to sickle cell pneumopathy is interesting but lacking scientific or theoretical support. Incentive spirometry provides similar benefits (chiefly cosmetic) in patients with other conditions as well.2

A more appropriate conclusion might be that chest-wall pain causes atelectasis. Incentive spirometry modifies this. The benefits and costs of this intervention are speculative. Because there was no quantifiable benefit, cost effectiveness is unlikely to be shown.

William W. Merrill, M.D.
New Orleans Veterans Affairs Medical Center, New Orleans, LA 70146

2 References

1. 1

   Bellet PS, Kalinyak KA, Shukla R, Gelfand MJ, Rucknagel DL. Incentive spirometry to prevent acute pulmonary complications in sickle cell diseases. N Engl J Med 1995;333:699-703
   Full Text | Web of Science | Medline

2. 2

   Johnson D, Kelm C, To T, et al. Postoperative physical therapy after coronary artery bypass surgery. Am J Respir Crit Care Med 1995;152:953-958
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The benefits and costs of incentive spirometry in patients with sickle cell diseases who are hospitalized with acute chest or back pain above the diaphragm are not speculative, as Dr. Merrill suggests. Our prospective, randomized trial demonstrated that incentive spirometry can prevent the pulmonary complications (atelectasis or infiltrates) associated with the acute chest syndrome in such patients. Although the acute chest syndrome is usually self-limited, single episodes can cause substantial morbidity and even death. Powars et al.1 found that the most important risk factor associated with chronic lung disease in patients with sickle cell diseases was the total number of episodes of the acute chest syndrome, and Platt et al.2 determined that the acute chest syndrome was a significant risk factor for early death in patients with sickle cell anemia who were 20 years of age or older. It is therefore reasonable to hypothesize that the prevention by incentive spirometry of pulmonary complications (atelectasis or infiltrates) associated with the acute chest syndrome might prevent chronic lung disease and early death. Our finding that incentive spirometry can prevent atelectasis or infiltrates associated with the acute chest syndrome in patients with sickle cell diseases who are hospitalized with chest or back pain above the diaphragm is evidence that atelectasis and infiltrates play a part in the pathogenesis of sickle cell pulmonary disease. The incentive spirometer is inexpensive: the standard Volurex incentive spirometer costs the hospital $10.20. In our study, the patients' nurses supervised the use of the incentive spirometer as part of nursing care. No other therapist was needed. The mean (±SD) length of hospital stay in the 9 hospitalizations during which pulmonary complications occurred was 6.4±1.9 days, as compared with 3.6±2.1 days in the 29 hospitalizations during which no pulmonary complications occurred (P = 0.001). The prevention of pulmonary complications by the use of incentive spirometry was clinically beneficial and decreased the average cost of hospitalization from $6,775 to $3,582 by decreasing the length of hospital stay.

Paul S. Bellet, M.D.
Karen A. Kalinyak, M.D.
Donald L. Rucknagel, M.D., Ph.D.
Children's Hospital Medical Center, Cincinnati, OH 45229-3039

2 References

1. 1

   Powars D, Weidman JA, Odom-Maryon T, Niland JC, Johnson C. Sickle cell chronic lung disease: prior morbidity and the risk of pulmonary failure. Medicine (Baltimore) 1988;67:66-76
   Web of Science | Medline

2. 2

   Platt OS, Brambilla DJ, Rosse WF, et al. Mortality in sickle cell disease -- life expectancy and risk factors for early death. N Engl J Med 1994;330:1639-1644
   Full Text | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Mary M. Reagan, Michael R. DeBaun, Melissa J. Frei-Jones. (2011) Multi-modal intervention for the inpatient management of sickle cell pain significantly decreases the rate of acute chest syndrome. Pediatric Blood & Cancer 56:2, 262-266
   CrossRef