Effectiveness of Teaching Breathing Exercise with Incentive Spirometry Combined with Facial Tissue Use in Elderly Patients with Hip Fracture

Abstract

Introduction Incentive spirometry (IS) is a widely used device for lung exercise to prevent post operative pulmonary complications. This includes its use among elderly patients with hip fractures, whose numbers are increasing annually. The traditional method of teaching elderly patients to use IS involves verbal explanation to help them understand how to inhale through their mouth to raise the ball in the IS before practicing with the device. However, this method can be challenging for elderly patients with memory and cognitive impairment, affecting their learning process. Teaching elderly patients to use IS with traditional methods may require more time, and some patients may struggle with distinguishing between inhalation and exhalation. This can result in patients exhaling or blowing, which does not raise the ball and is ineffective for lung expansion. This study introduces the use of facial tissue to help teach the correct inhalation technique. The facial tissue serves as a tangible way to evaluate proper mouth inhalation before practicing with the IS, leading to better patient comprehension and use of the IS.

Objective The objective of this study is to compare the duration of time teaching breathing exercises with IS, the duration the ball in the IS float, the number of balls the patient manages to float, the oxygen saturation levels, and the occurrence of pulmonary complications between the traditional teaching method and the method combined with facial tissue.

Design This study was a randomized experimental study that applied Kolb’s Experiential Learning Theory, which consists of Concrete experience, Reflective observation, Abstract conceptualization, and Active experimentation, as a framework for teaching patients breathing exercises with flow-oriented IS devices. Methodology The participants consisted of 78 elderly patients aged 65-90 years, who had undergone hip surgery. The participants were selected through purposive sampling based on the following inclusion criteria: 1) the ability to communicate effectively in Thai and were not in a state of acute delirium, as assessed using the Thai version of the 3D-CAM Algorithm-Thai version, and 2) no concurrent respiratory or heart diseases in uncontrollable stages, and no signs of unstable vital signs. The exclusion criteria were based on cognitive impairment, as measured by the General Practitioner Assessment of Cognition (GP-COG), with a score of < 4. Sample size calculation was performed using computer software according to the principles of power analysis for the Independent t-test for two mean groups, with a power of .80 and a Type I error of .05. Participants were randomly assigned to the experimental and control groups, equally in each group, using computerized random assignment through block randomization. The control group received instruction on IS using the traditional teaching method, while the experimental group incorporated facial tissue to aid in teaching deep inhalation before the patients practiced with the IS. From November 2022 to January 2024, data were collected by research assistants who were blinded using data record form, which included personal information, results of the IS training, and any pulmonary complications. Data analysis was performed using descriptive statistics, Independent t-test, Chi-square test, Mann-Whitney U test, and Fisher’s Exact test.

Results The control and experimental groups had mean ages of 79.23 years (SD 6.28) and 78.97 years (SD 6.83), respectively. The mean body mass index (BMI) were 23.03 kg/m² (SD 3.76) and 23.26 kg/m² (SD 4.07), respectively. The majority of participants were female, at 87.2% and 82.1%, respectively. When comparing the characteristics of the two groups, no statistically significant differences were found. The average duration of teaching breathing exercises with IS for the experimental group (M 3.03, SD 4.34 minutes) was significantly shorter than that for the control group (M 4.33, SD 4.06 minutes) (Z = -2.704, p = .007). However, the number of balls the patients were able to float, the duration the balls floated after training, and the number of balls floating on the discharge day did not show statistically significant differences between the two groups (p > .05). The average oxygen saturation levels on the day before surgery, the day after surgery, and the discharge day, as well as the occurrence of hypoxemia and atelectasis in both groups, did not differ significantly (p > .05). Additionally, no cases of hospital-acquired pneumonia were found in either group during their hospital stay.

Recommendation Nurses and the healthcare team can use facial tissue as a tool to teach patients how to practice inhaling to “suck” air into their lungs through the tissue. This approach allows patients to have a direct experience of reviewing the “sucking” technique through observation, understanding, and practicing the method of mouth breathing. As a result, patients gain confidence and are able to use IS correctly, with less time spent on instruction compared to the traditional teaching method.