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Critical Care Questions for Hyperinflation Therapies

Terms in this set (78)

What is positive pressure ventilation?
Power source forces air into lungs developing a positive intrapulmonary pressure that expands the lungs.

*most common form of mechanical ventilation
What does IPPB stand for?
Intermittent Positive Pressure Breathing.
Indications for IPPB therapy?
1. To improve lung expansion. (atelectasis)

2. Aid in secretion removal of patients who can't take deep breaths. (Neuromuscular disorders, post-op abdominal or thoracic surgery)

3. To provide short-term ventilatory support.

4. To deliver aerosolized medications. (Patients with ventilatory muscle weakness or those who are unable to hold an optimal breathing pattern.)

5. To induce a sputum sample for culture and sensitivity or other diagnostic studies.
Please give an example of clinical situations in which IPPB therapy is indicated.
Patient cannot do IS therapy (cannot generate a VC greater than 10-15 mL/kg, is in a coma, a quadriplegic, neuromuscular disorders)
When the IPPB machine delivers higher than normal spontaneous tidal volumes, will this increase or decrease rising PaCO2 levels?
Decrease
Hazards/Complications associated with IPPB therapy?
1. Elevated intrathoracic pressure. (tachycardia, hypertension, anxiousness, and a headache.)

2. Pulmonary barotrauma (acute chest pain, dyspnea and decrease in SpO2)

3. Gastric Distension. (nausea, vomiting and possible aspiration of stomach contents.)

4. Hyperventilation. (dizziness, tingling in digits)

5. Excessive Oxygenation-Hyperoxia

6. Increased airway resistance

7. Airtrapping
Symptoms of elevated intra-thoracic pressures?
...
Symptoms of a pneumothorax?
...
What kind of delivered pressures can cause gastric distension?
Greater than 20-25 cm H2O
How can gastric distension be prevented?
Usually this is a risk with neurologically impaired patients with treatment being administered with a mask. To avoid gastric distension, an NG tube should be placed, or avoid excessive pressures.
How can you help prevent the patient from hyperventilating when receiving an IPPB treatment?
Maintain the respiratory rate between 10-12 breaths per minute.
True or False: An IPPB treatment can cause an increase in air trapping in a COPD patient?
True
Name an ABSOLUTE contraindication for administering an IPPB treatment.
Tension Pneumothorax without a functioning chest tube.
Name RELATIVE contraindications for IPPB therapy.
1. Patients with bullous disease or bleb viewed on chest x-ray.

2. Recent facial, oral or skull surgery.

3. Active Hemoptysis; coughing up blood indicates that a tear has occurred in the airway or lung tissues.

4. Hemodynamic instability; hypotensive, tachycardia

5. Elevated ICP/recent head injury or neurosurgery

6. Tracheoesophageal (T-E) fistula/recent esophageal surgery

7. Active (untreated) TB; bad for the practitioner

8. Nausea, air swallowing, singulation (hiccups)
What are the three main settings for IPPB machine?
Sensitivity (-1 cm H2O)

Flow (15 LPM)

Pressure (15 cm H2O)
What is respiratory failure?
A state when the patient cannot effectively remove the CO2 from the body.
What is PaO2? What is the normal range?
Partial pressure of O2 in the arterial blood. 80-100 mmHg
What is PaCO2? What is the normal range?
Partial pressure of CO2 in the arterial blood. 35-45 mmHg
Like Incentive Spirometer, IPPB therapy is used to manage atelectasis. Specifically, when would IPPB therapy be indicated over IS therapy?
If IS therapy is not working.
If your patient is in a coma or has neuromuscular disorders, or if your patient is a quadriplegic.
When your VC is < 10-15 mL/kg
During administration of an IPPB treatment, you notice the system pressure rises above the set pressure to end inspiration. What should you instruct the patient to do?
Allow the machine to give you a deep breath.

Also tell the patient to relax.
A patient is having difficulty initiating each breath with the IPPB machine. What should you adjust?
You should lower the sensitivity.
What control is used to increase the volume delivered by an IPPB machine?
The flow control knob.

Turning the knob to a higher number causes a greater flow into the mainstream breathing circuit and nebulizer (decreases inspiratory time).

If the flow control knob is turned to a lower number this causes less flow and increases inspiratory time.
An IPPB machine cycles on with patient effort but does not shut off. The most likely cause of this problem is?
The sensitivity is too low.
What should the initial sensitivity be set at? (IPPB)
-1 cm H2O
What should the initial flow be set at? (IPPB)
15 LPM
What should the initial pressure be set at? (IPPB)
15 cm H2O
What are the units for sensitivity? (IPPB)
cm H2O
What are the units for flow? (IPPB)
LPM
What are the units for pressure? (IPPB)
cm H2O
What does CPAP stand for?
Continuous Positive Airway Pressure
When is CPAP therapy indicated?
CHF
Atelectasis
The positive pressure is maintained throughout the ___________ and __________ phases when receiving CPAP therapy.
Inspiration ; Expiration
What range of pressures are used when administering CPAP therapy?
5-20 cm H2O
What does OSA stand for?
Obstructive Sleep Apnea
What does CHF stand for?
Congestive Heart Failure
Name some benefits of CPAP therapy.
Increases FRC (resolution of atelectasis)
Helps to open distal alveoli for better ventilation.
Increase compliance to decrease WOB.
Secretion removal.
Name some contraindications for CPAP therapy.
NO ABSOLUTE CONTRA.

Relative:
Hemodynamic instability
Hypoventilation
Nausea
Claustrophobia
Untreated Pneumothorax
Elevated ICP readings
Patients must be observed carefully when administering CPAP. List some items that should be observed while the patient is on CPAP therapy.
Monitor the vital signs closely.

Watch for hypoventilation.

Also watch for nausea and vomiting.
Name 3 clinical assessments that can be observed to determine whether or not the CPAP treatment is effective.
Improvement in breath sounds, vital signs.

Resolution of atelectasis on CXR.

Improvement of oxygenation.
What alarm system is ESSENTIAL for monitoring patients receiving CPAP therapy?
Low pressure alarm.

This monitors the pressure at the patient's airway. If the low pressure alarm is sounding the patient is not receiving the prescribed therapy and thus not effective.
Adequate flow is important to maintain CPAP levels. How can you determine if you are giving enough flow to the patient?
The flow is adequate if pressure drops no more than 1-2 cm H2O on a deep inspiration.

If not, you'll need to increase the flow.
CPAP is used to increase which of the following?

a. Functional residual capacity
b. Peak expiratory flow rate
c. FEV1
d. PaCO2 levels
FRC
The IPPB is noted to be stuck in the inspiratory position. Name 3 causes for this problem.
There is a leak in either the circuit or the patient does not have a tight seal around the mouthpiece.

A sticking valve.
During the IPPB treatment, a patient suddenly complains of sharp, left sided chest pain. She is turning blue and very SOB. What should you do as a therapist if this is occurring?
Call for help, administer 100% O2, stop the treatment, call for a CXR

(Patient is most likely having pneumothorax)
When is the use of EzPAP preferred over IPPB?
Always, because it's much easier for the patient and the therapist, but you get the same result.
What is purpose of an EzPAP treatment?
This is another type of therapy used for lung expansion and the treatment and prevention of atelectasis.
Can you administer an EzPAP treatment in line with aerosol therapy?
Yes
What should be the initial liter flow for an EzPAP treatment?
5 LPM
How would you instruct a patient to perform an EzPAP treatment?
Place mouthpiece in the patient's mouth and instruct patient to breathe easily against the pressure from the device.

Take a breath in and they will feel pressure upon exhalation.

You'll look at the manometer to see what kind of pressure they're generating. Slowly adjust flow meter (increase or decrease liter flow) until desired expiratory airway pressure is reached. Typically you want an expiratory pressure of 10-20 cm H2O.
How would a therapist monitor airway pressures during an EzPAP treatment?
By using a manometer
What type of pressures should be achieved during an EzPAP treatment?
10-20 cm H2O
What are the contraindications for using the EzPAP therapy? Is there an ABSOLUTE contraindication?
NO ABSOLUTE CONTRA.

Relative:

Elevated ICP
Esophageal surgery
Hemoptysis
Nausea and vomiting
Middle ear pathology
Recent facial or cranial surgery
Active TB
Pulmonary Embolism
You are called for a Hyperinflation protocol on a patient who recently underwent a small bowel obstruction surgery. This patient has developed a low grade temp, bilateral infiltrates/atelectasis on this morning CXR, Heart Rate 120, RR 24-28, Breath sounds are coarse. Current therapy consist of Incentive Spirometry, however the patient has not an active participate in his care. What 3 criteria are you going to evaluate to determine what therapy the patient should be placed on? What therapy would you recommend for this patient?
1. CXR (diagnosis of atelectasis)
2. History of asthma or COPD
3. VC greater or less than 10-15 mL/kg IBW

You'd put them on EzPAP.
During an IPPB treatment, a patient complains of dizziness and a tingling sensation in her fingers. What is the patient doing? What would you document in the chart about this treatment?
This patient is hyperventilating.

You'd need to document the symptoms the patient is having, what medication they're on, how you had to reinstruct them, who you told they are having these symptoms
While administering an IPPB treatment to a patient with known COPD, the patient becomes very SOB and cyanotic. What would you do?
Stop the treatment and assess them (make sure they don't have a pneumothorax).
How can you determine if the IPPB or EzPAP therapy is working? What sort of outcomes indicate the therapy is working.
Improved breath sounds
Improved CXR
Improved Vital signs
Improved oxygen saturation (could be weaned)
Patient's subjective response
The patient will not take an effective IPPB treatment no matter what you do. How can you help this patient?
Give the treatment by ambu mask or Bennett seal
How can you determine what the exhaled tidal volumes are when taking an IPPB treatment?
Hook up a Wright spirometer to the machine.
When administering an IPPB treatment via mask, what sort of things as a respiratory therapist should you be watching for?
Gastric Distension
Signs of vomiting
If you were to start a new patient on IS therapy, how can you determine what the IS goal should be?
10 mL/kg IBW x 2
How often should IS therapy be performed?
10 times per hour while awake
If you push in the air-mix control knob on the IPPB will your delivered flow increases or decreases?
Decrease
Your patient complains of difficulty in starting the IPPB treatment. You would adjust which of the following controls?

a. Pressure
b. Flow
c. Sensitivity
d. Terminal flow
Sensitivity
All the following indicate the need for IPPB EXCEPT?

a. Delivery of medications to a patient who cannot coordinate the use of an MDI or a SVN
b. Treatment of a comatose patient with atelectasis
c. The need for a substitute for IS in a patient with an IC that is 60% predicted
d. Treatment of a cooperative patient with atelectasis
D
Your patient is quite weak and despite repeated attempts to raise the ball marker on the flow displacement-type Incentive Spirometer, they are unable to raise the ball near the goal. What should you recommend?

a. Have them continue trying
b. Recommend they be switched to IPPB therapy
c. Change them to a volume displacement-type spirometer
d. Discontinue the treatment because it is not effective
C
IS therapy is indicated when a patient's post-operative IC is what percentage of the pre-operative IC?

a. Between 30-50%
b. Between 50-80%
c. Between 80-90%
d. Greater than 90%
30-50%
If PFT (Pulmonary Function Test) results are not available, what should the initial IS goal be set at?

a. The IC measured at the bedside
b. The VC measured at the bedside
c. Three times the tidal volume measured at the bedside
d. Twice the tidal volume measured at the bedside
D
It is recommended that IS be performed how often while the patient is awake?

a. At least 5 times/hr
b. At least 10 times/hr
c. At least 20 times/hr
d. At least 10 times/day
B (while awake)
If IS has been successful, which breath sound can be heard in the areas where atelectasis was noted before the treatment?
a. Bronchial
b. Absent
c. Normal vesicular
d. Tracheal
C
Your patient has just performed several excellent IS efforts. She complains of tingling fingers and dizziness. Your response would be to...

a. Have her continue with additional IS maneuvers
b. Check her fingers and forehead for cyanosis
c. Call her physician to cancel the treatment order
d. Tell her to relax and breathe quietly until she feels normal again
D
You are ordered to give an IPPB treatment to a comatose patient who has lip ulcers. What patient-machine connection would you use?

a. Mouthpiece
b. Facemask
c. Bennett seal with mouthpiece
d. Endotracheal tube adaptor for intubation
Facemask
The sensitivity control should be set at what level at the start of an IPPB treatment?

a. 0 cm H2O
b. -1 cm H2O
c. -3 cm H2O
d. -5 cm H2O
-1 cm H2O
While coaching an active IPPB treatment, you notice that the needle on the pressure manometer "bounces" around as the pressure increases. To better adjust treatment to the patient's needs, you would do which of the following?

a. Increase the flow
b. Decrease the flow
c. Increase the peak pressure
d. Increase the sensitivity
Increase the flow
You would stop an IPPB treatment under which of the following conditions?

a. You suspect that the patient has just developed a pneumothorax
b. The patient has a difficult time keeping his lips sealed
c. The patient's wheezing is getting worse, and he complains of SOB
d. The patient coughs up large amounts of blood
A,C,D
A patient who was initially anxious about taking an IPPB treatment and needing a fast breath is now breathing in a more relaxed manner. What adjustment would you make to allow for a longer inspiratory time?

a. Decrease the peak pressure
b. Increase the sensitivity
c. Set the air-mix know to allow room air to be entrained
d. Decrease the flow
Decrease the flow
A patient you are evaluating has a spontaneous tidal volume of 400 mL and has been diagnosed with atelectasis after bowel surgery. IPPB has been ordered. What would you recommend as the minimal volume goal?

a. 300 mL
b. 400 mL
c. 500 mL
d. 800 mL

Remember that the patient's IPPB volume should be at least 25% greater than the patient's spontaneous tidal volume
500 mL
You are giving an IPPB treatment on the Bird Mark 7 unit. To give the patient 100% oxygen, you push in the air-mix control knob. What effect does this adjustment have on the flow rate to the patient?

a. Decrease the flow of gas
b. Increase the flow of gas
c. No effect
d. Increases the sensitivity
Increase the flow of the gas
Your patient is going into pulmonary edema. She has rales in both lung fields, has cyanotic lips and nail beds and is coughing up pink, frothy sputum. What O2 percentage would you recommend for her Mask CPAP?

a. 21%
b. 40%
c. 80%
d. 100%
100%
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