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I COUGH for Prevention of Postop Pulmonary Complications


Clinical question

Does implementation of the I COUGH strategy improve pulmonary outcomes in postoperative patients?

Bottom line

Although not statistically significant, data from this before-and-after trial shows that the I COUGH strategy (emphasizing lung expansion, early mobilization, oral hygiene, and patient and provider education) may decrease postoperative pulmonary complications in hospitalized patients. (LOE = 2c)


Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013;148(8):740-745.

Study design


Funding source

Unknown/not stated




Inpatient (any location)


Data from the National Surgical Quality Improvement Program (NQSIP) showed that the Boston Medical Center was a high outlier for postoperative pulmonary complications. To address this, a pulmonary care working group including surgeons, internists, nurses, and respiratory therapists was formed. The group reviewed the literature on preventing postoperative pulmonary complications and devised the I COUGH strategy: (1) Incentive spirometry, (2) Coughing and deep breathing, (3) Oral care, (4) Understanding (patient and family education), (5) Getting out of bed, and (6) Head-of-bed elevation. Postoperative pain control was also emphasized. Educational materials including videos and brochures were developed for patients and families and distributed in surgery and perioperative clinics. Incentive spirometry technique was taught and reinforced in the preoperative setting. Frontline nurses and physicians also received education regarding the baseline outcomes data and the reasons for developing the program. Finally, standardized order sets outlining the components of I COUGH were created. The I COUGH strategy was implemented for all hospitalized general and vascular surgery patients in the institution. More patients were out of bed postintervention than preintervention (70% vs 20%; P < .001). Similarly, more patients had incentive spirometry available and within reach postintervention (77% vs 53%; P < .001). Note, however, that the preintervention audits were unannounced observations of nursing practices whereas postintervention audits were by review of nursing documentation only. Although not statistically significant, the NSQIP data revealed trends toward decreased incidences of postoperative pneumonia (2.6% vs 1.6%; P = .09) and unplanned intubations (2.0% vs 1.2%; P = .09) after I COUGH implementation. National averages for postoperative pneumonias and unplanned intubations for comparable hospitals during this period were 1.4% to 1.7% and 1.4% to 1.6%, respectively.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

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