IPPB Therapy

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IPPB

the therapeutic application of inspiratory positive pressure to the airway of a spontaneously breathing patient

Indications for IPPB

increased work of breathing
hypoventilation
delivering medication when a nebulizer is not effective enough
inadequate cough
increased airway resistance
atelectasis
pulmonary edema
to aide in weaning from a mechanical ventilator

Contraindications for IPPB

untreated pneumothorax (ABSOLUTE CONTRAINDICATION)
tuberculosis
subcutaneous emphysema
hemoptysis (spitting up of blood)
closed head injury- increases ICP
bullous disease
cardiac insufficiency
COPD with air trapping
uncooperative patients

Contraindications of IPPB

hemodynamic instability (i.e. MI, hypovolemic shock)
increased ICP from neurosurgery or trauma
facial, oral, esophageal surgery
trachesophageal fistula
availablity of a cheaper, simpler therapy (ex: neb, IS, PEP)

Hazards and Complications of IPPB

excessive ventilation
excessive oxygenation
decreased cardiac output
increased ICP
pneumothorax
hemoptysis
gastric distention
nosocomial infection
decreased blood pressure

Avoiding Decreased Cardiac Output and Increased ICP on IPPB

use a 1:2 or a 1:3 I.E. ratio to allow for enough expiratory time
during expiration, no positive pressure is applied, so this allows enough time for the heart to fill with blood

Pneumothorax on IPPB

IPPB may result in better distribution of ventilation, with gas entering poorly ventilated areas like blebs

Signs and Symptoms of Pneumothorax

sudden, sharp pain
shortness of breath
unilateral chest wall rise
increased heart rate
increased respiratory rate
IPPB reaches pressure limit much sooner than before

H&C= Excessive Oxygenation

excessive oxygenation of O2 sensitive patients; may knock out a patients hypoxic drive. machines are pneumatically powered and driven by oxygen so the RCP may give the patient too high of an FiO2
increased air trapping due to excessive ventilation of partially obstructed areas of lungs
possibility of post treatment difficulty breathing due to an increased FRC

H&C: Increased ICP

increased airway pressures cause an increased intrathoracic pressure, thereby impeding venous return from the brain

H&C: Hemoptysis

due to bronchial venous bleeding secondary to a tumor or blood vessel rupture
increased cough effectiveness after a treatment

H&C: Gastric Insufflation

can occur with a normal treatment, but seen more with mask treatment
occurs less with alert patients than those who are not alert

H&C: Nosocomial Infection

improperly cleaned equipment
psychological dependence
increased airway resistance from turbulent flow

Proper Administration of IPPB

assemble equipment and check machine for leaks
check MD order
review chart to check for contraindications
wash hands
ID patient
connect the circuit to IPPB and plug in gas source
place meds
pt. assessment
position pt. in an upright position; allows for better ventilation
place mouthpiece in patients mouth and encourage patient to keep lips sealed tight to breathe ONLY though the mouth (use noseclips)
instruct patient to sip on mouthpiece to fill the lungs until the machine cycles off. have patient hold his breath for a count of 3 before exhaling

Setting Machine Parameters

I-pressure: start lower than the desired pressure and gradually increase as treatment continues
increase flow rate as pressure increases to maintain the same I-time

Administering IPPB

check vitals halfway through treatment
after 10 minutes or when medication is fully nebulized, have patient cough
check vitals again
encourage patient to cough periodically for the next 30 minutes to 2 hours as the effect of the medication peaks
wash hands

Administration Tips

a correctly administered IPPB treatment should provide the patient with a tidal volume greater than they would achieve on their own
an agressive RT regimen that includes IPPB has been shown to be as effective as a therapeutic bronchoscopy in treating lobar atelectasis
try to minimize high pressures, irregular I:E ratiors and excessive flows to avoid patient discomfort and unwanted side effects

IPPB Order

should contain the following:
objectives of therapy
specific frequency
duration
medication

IPPB Starting Pressure

10-15 cmH20

IPPB Starting I:E ratio

1:2 or 1:3

IPPB Starting Flow Rate

varies according to patients needs but keep the lowest flow possible that the patient can tolerate (how fast the breath is given) to avoid hyperventilation

IPPB Cycle Rate

7-10 breaths per minute

I-time

2-4 seconds

Breath Hold

2 seconds

E-time

4-6 seconds

IPPB Administration

machine delivered tidal volume must exceed the patients spontaneous tidal volume
there should be a 25% increase in the patients tidal volume
75% of the patients present vital capacity
must also deliver 10-15 mL/kg of body weight

Goals of IPPB

improved breath sounds
improved sputum production
improved pulse ox
improved ABG results
improved PFT
improved peak flow/slow vital capacity
improved CXR
favorable subjective responses

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