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IPPB & Lung Expansion Therapy
Terms in this set (62)
What patients need lung expansion therapy?
Patients who have undergone thoracic or abdominal surgery.
What types of complications can occur with thoracic or abdominal surgery? (3 complications)
3. Acute respiratory failure
Which of the three complications happens most frequent?
How can the complications be minimized or eliminated?
With appropriate respiratory care including lung expansion therapy
What are the 4 types of Lung Expansion Therapies?
1. Intermittent Positive Pressure Breathing
2. Incentive Spirometry
3. Continuous Positive Airway Pressure
4. Positive Expiratory Pressure
What is atelectasis?
It is the abnormal collapse of distal lung parenchyma
What are the two primary types of atelectasis?
1. Reabsorption Atelectasis
2. Passive Atelectasis
What is reabsorption atelectasis?
It occurs when something is blocking the normal ventilation of air through the airways. The gas that is beyond the blockage is absorbed by the blood after which the alveoli collapse
What often causes reabsorption atelectasis?
It is often caused by mucus plugging or lesions/tumors
What is passive atelectasis?
It occurs when the patient consistently breathes small tidal volumes.
In what cases is passive atelectasis seen? (4 different scenarios)
1. Patients on bed rest
2. After general anesthesia
3. During use of sedatives
4. In patients where deep breathing is painful (chest, abdominal surgery, broken ribs, etc.)
What types of patients need lung expansion therapy?
1. Post-op patients
2. Highest risk surgeries are upper abdominal and chest
3. Lower abdominal and spinal surgery also present increased risk
4. Bedridden patients
5. Patients with history of lung disease and cigarette smoking
What is the first sign/alert that a patient could have atelectasis?
The patient's medical history. This includes surgeries, smoking history and chronic lung disease.
Besides looking at the patient's history, what else do you do to see if a patient has atelectasis?
You perform a physical exam. Patients will have increased heart rate (due to hypoxemia), breath sounds (crackles, bronchial / diminished), chest x-ray
How do lung expansion therapies work?
All lung expansion therapies work by increasing the lung volumes.
How do they increase lung volumes?
By increasing the transpulmonary pressure gradient.
What happens when high pressured gas is forced into the alveoli?
The alveoli are forced to expand.
What is incentive spirometry designed to do?
Mimic natural sighing by encouraging patients to take deep, slow breaths
Incentive spirometry is designed to prevent and treat what, by doing what?
Atelectasis by encouraging deep breathing
Why can surgeries cause atelectasis?
Surgeries cause pain and the pain causes patients to develop a pattern of rapid, shallow breathing and the reduced tidal volumes can lead to passive atelectasis.
How would you instruct a patient to use an IS?
Take 10 deep breaths every hour, each followed by a 3-5 second breath-hold.
What is the purpose of a breath hold?
A sustained maximal inspiration causes the pleural pressure to drop well below normal. This increases the transpulmonary pressure gradient, which is sustained for a few seconds with a breath hold.
**Atelectasis can frequently be prevented by increasing transpulmonary pressure gradient
What does positive airway pressure therapy do?
It helps mobilize secretions and treat atelectasis
What does positive airway pressure therapies include? (3 types)
What is positive expiratory pressure and what is it used for?
It is the most frequently used PAP therapy in terms of assisting in secretion clearance. It involves active expiration against a variable flow resistance.
How does PEP help mobilize secretions? (3 ways)
1. Improving distribution of inspired volume in the lung by means of collateral circulation (pore of Kohn)
2. Prevention of airway collapse on exhalation
3. Increased pressure during exhalation in an area distal to the site of mucus obstruction.
What is thera-PEP?
A device that provides variable resistance to exhalation. It can be used as stand alone or combined during nebulizer therapy. Resistor is numbered 1-6 with 1 being least resistance and 6 being most.
How does thera-PEP work?
During exhalation, ventilation travels from an aerated lung unit to an area behind the secretion, accomplished through the pores of kohn and canals of lambert. With the secretions cleared, full aeration is restored to the lung.
How is PEP achieved via thera-PEP?
By inhaling a larger than normal tidal volume, but not to vital capacity and then exhaling through the device, normally not forcefully. The valve creates back pressure.
What PEP levels are used during exhalation?
How would you instruct a patient to do thera-PEP?
Do 10-20 breaths, followed by 2-3 "huff" coughs.
What is considered a full session of thera-PEP?
A full session consists of 40-100 breaths
What would you set the resistor at?
Start at 6 (most) and lower to slow down the breath to approximately a 1:3-4 ratio
What is high frequency oscillation used for?
Used for several mucus clearing techniques/devices.
How can HFOA aid in mucus clearance? (3 ways)
1. Altering mucus rheology
2. Enhanced mucus-airflow interaction
3. Reflex mechanisms
How can oscillations be made?
They can be made mechanically by a device or self-generated by exhalation through an oscillatory device
What is a flutter valve?
It is a device that combines PEP with HFOA. It is a pipe shaped device with a steel ball and is POSITION DEPENDENT.
What does the steel ball do?
The weight of the steel ball creates the PEP (approx. 10-25 cmH2O)
How is a flutter valve used?
The patient slowly inhales a slightly elevated tidal volume breath and holds for 2-3 seconds.
What is acapella therapy?
It combines PEP with HFOA. The internal mechanism creates vibration and PEP and NOT POSITION DEPENDENT
How does a patient use the acapella?
They slowly inhale a slightly elevated tidal volume breath 10-20 times and holds for 2-3 seconds, followed by 2-3 "huff" coughs. They then exhale fairly fast by not full force. Repeat.
What is IPPB?
It is an inspiratory maneuver which provides a means of maximally inflating the lungs by delivering positive pressure. It follows an inspiratory effort by a spontaneously breathing patient.
How long is IPPB delivered for?
10 to 20 minutes for the purposes of delivering aerosolized medications and/or hyperinflating the lungs
What are the 7 indications for IPPB?
1. Clinically diagnosed atelectasis not responsive to other therapies
2. Patients at high risk for atelectasis and can't do IS
3. Need for short-term ventilatory support for patients who are hypoventilated as an alternative to tracheal intubation and continuous ventilatory support.
4. Reduced pulmonary fuctions evidenced by reductions in timed volumes, and vital capacity
5. Neuromuscular disorders or kyphoscoliosis with associated decreases in lung volumes and capacities
6.Fatigue or muscle weakness w/ impeding respiratory failure
7. The need to deliver aerosol medication in patients who are unable to take a deep breath
What is the absolute contraindication for IPPB?
What are the 10 relative contraindications?
1. Intracranial pressure > 15 mmHg
2. Hemodynamic instability
3. Recent facial, oral, or skull surgery
4. Tracheoesophageal fistula
5. Recent esophageal surgery
6. Active hemoptysis
7. Nausea, Air swallowing
8. Active, untreated tuberculosis
9. Radiographic evidence of bleb
What are the 6 hazards and complications of IPPB?
1. Respiratory alkalosis
2. Gastric distention
3. Increased airway resistance
4. Barotrauma, pneumothorax
5. Nosocomial infection
What happens if the patient starts hyperventilating?
If they hyperventilate and experience tingling and dizziness, stop the treatment, reinstruct the patient on how to do the treatment and restart.
What are the 6 potential outcomes of IPPB?
1. Improved IC or VC
2. Icreased FEV-1 or peak flow
3. Enhanced cough or secretion clearance
4. Improved chest radiograph
5. Improved breath sounds
6. Improved oxygenation
Pressure ventilators are what in terms of pressure and volume?
Pressure constant and volume variable
What is the delivered TV dependent on?
It is dependent on the patient's lung compliance & airway resistance
If the TV increases what happened?
The compliance increases, airway resistance decreases
If the TV decreases what happened?
The compliance decreases, airway resistance increases
What are the initial settings for IPPB?
Sensitivity = -1 to -2 cm H2O (Pressure Trigger)
Pressure Limit = Initially set at 10-15 cmH2O
Flow = 20-25 LPM
RR = 6-10 bpm
IPPB tidal volumes should be what?
10-15 ml/kg of IBW or at least 25% higher than during normal breathing
How do you know if the IPPB treatment was effective?
1. TV during IPPB is greater than spontaneous breathing (by at least 25%)
2. FEV-1 or peak flow increases following treatment
3. Cough is more effective
4. Secretion clearance enhanced
5. Improvement in chest x-ray
6. Breath sounds improved
7. Favorable patient subjective response
What does a mushroom valve do?
The mushroom valve keeps air from escaping during inhalation so air goes directly to the patient. During exhalation, it rises and allows the patient to exhale the air out.
Problem 1: Large negative pressure swing prior to the IPPB unit cycling "on". What's wrong?
The sensitivity or trigger setting is set incorrectly making it more difficult to trigger the machine on. Adjust the trigger level so that only -1 or -2 cmH2O are needed to trigger inspiration.
Problem 2: The patient has difficulty initiating breath. How would you fix this problem?
1. Adjust the sensitivity so that the patient has to generate only between -1 to -2 cmH2O pressure to start inspiration
2. Make sure machine is connected to 50 psi O2
3. Ensure the flow control is turned on
4. Ensure machine tubing connections are all tight
5. Ensure there are no leaks around the mouthpiece/mask/cuff
Problem 3: The patient has difficulty shutting breath off. How would you fix this?
1. Tighten all tubing connections
2. Ensure there are no leaks around the mouthpiece/mask/cuff
Problem 4: During inspiration, the manometer needle stays in the negative area for the first half of the breath and than rises to the positive area during the last half. How would you fix this?
1. Increase the flowrate
Problem 5: The IPPB machine repeatedly cycles on shortly after the patient has begun the expiratory phase. How would you fix this?
1. Decrease the machine sensitivity from -2 to -3, etc.
2. Ensure the apnea alarm is turned off
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