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Incentive Spirometry After Bariatric Surgery: The Importance of Patient Compliance To the Editor We read with great interest the article by Pantel et al1 on the effect of routine incentive spirometry (IS) orders after bariatric surgery on patients with postoperative hypoxemia (defined as a peripheral saturation of oxygen level less than 92% without oxygen supplementation at 6, 12, and 24 hours after operation) and 30-day pulmonary complications. In this trial, 112 bariatric surgery patients were randomized to receive standard postoperative IS orders (including an IS device and a recommendation to use it 10 times every hour while awake) and 112 were randomized to no postoperative IS. Of note, postoperative IS was strictly an order set for nursing care, without any control over its implementation or patient performance. Interestingly, self-reported logs from 12 patients prior to the study showed a mean frequency of IS use of 4.1 times on postoperative day 1 and 10.4 times on day 2. This is an incredibly low compliance compared with the recommended 10 times per hour while awake.1 The authors acknowledge this limitation but only justify it as within the usual reported use range. Previous studies indicate that IS compliance is scarcely and inconsistently reported in clinical trials, which is essential to evaluate its effectiveness.2,3 Thus, the lack of significant benefit by IS in this study is not surprising and does not detract from the technique itself but rather its implementation. We recently showed in a multicenter prospective study4 that atelectasis and other, even mild, pulmonary complications are significantly associated with early postoperative mortality, intensive care unit admission, and hospital stay in patients classified as American Society of Anesthesiologists physical status 3 after 2-hour and longer noncardiothoracic surgery. Our findings emphasize the need to increase (not reduce) our efforts to minimize complications such as atelectasis and postoperative hypoxemia. Incentive spirometry, although simple and relatively inexpensive, adds up as a cost and may seem a waste of resources in its current use. However, very few practical alternatives (if any) exist to decrease atelectasis and improve oxygenation in the early postoperative period before patients can ambulate. Further, the average cost of a single pulmonary complication (approximately $25 000)5 would quickly efface the annual IS cost reported by the authors (approximately $33 000).1 Trials with adequate methodological assessment of patient IS performance (both frequency and effort) are still needed.3 To abandon IS without aggressive implementation would mean discarding an inexpensive opportunity to decrease mild pulmonary complications without an alternative. Instead, we should accept that IS performance by surgical patients is poor and consider efforts to reinforce and monitor adequate IS performance. Only if those produce no effect should IS be abandoned.