131 Lung expansion therapy II

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Lung Expansion Therapy Causes & types of Atelectasis Resorption atelectasis… occurs when lesions or mucus plugs are present in airways & block ventilation of affected region Gas distal to obstruction is absorbed by passing blood in pulmonary circulation, which causes nonventilated alveoli to collapse Passive atelectasis…caused by persistent use of small tidal volumes by patient Use of sedatives, general anesthesia, bed rest, deep breathing prohibited due to pain Abdominal surgery & broken ribs

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Lung Expansion Therapy Who needs lung expansion therapy Neuromuscular patients Heavily sedated patients Upper abdominal or thoracic surgery Spinal cord injury Bedridden patients Postoperative patients *** highest risk

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Lung Expansion Therapy What are the clinical signs of atelectasis Physical signs Respiratory rate will increase Late-inspiratory crackles Bronchial sounds may be present Tachycardia Diminished breath sounds Chest x-ray… direct signs…indirect signs

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Lung Expansion Therapy How does Lung Expansion Therapy Work? Increases transpulmonary pressure gradient Greater the gradient the more alveoli expand Spontaneous deep inspiration increases gradient by decreasing pleural pressure Positive pressure increases gradient by raising pressure inside alveoli Two approaches… Incentive spirometry Positive airway pressure IPPB PEP therapy

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Lung Expansion Therapy Incentive Spirometry Design to mimic natural sighing Performed using devices that provide visual clues to volumes or desired flow Volume goal set based on predicted values or observation of initial performance Maneuver Sustained maximal inspiration (SMI) Slow deep inhalation with breath hold 5-10 sec Physiology Inspiratory phase…drop in pleural press. caused by expansion of thorax is transmitted to alveoli causing flow of air from airway to alveoli

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Lung Expansion Therapy Incentive Spirometry Contraindications Unconscious patients or those unable to cooperate Patients who cannot properly use IS device after instruction Patient unable to generate adequate inspiration VC < 10 mL/kg IC < 1/3 predicted normal Hazards Hyperventilation and respiratory alkalosis Discomfort secondary to inadequate pain control Hypoxemia (with interruption of therapy Exacerbation of bronchospasm Fatigue

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Introduced in 1947 by Motley Volatile history… early use was widespread and popular Predominate mode of therapy in 70’s Under attack in 80’s for its overuse Proper use Patients carefully chosen Indications for therapy specifically defined Goals of therapy clearly understood Treatment be properly administered and monitored by RCP Physiological Principle Positive pressure transmitted to alveoli to pleural space…passive exhalation

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Indications Patients clinically diagnosed with atelectasis that is not responsive to other therapies Useful for pts at high risk for atelectasis & not cooperative with simple procedures Should not be used as single treatment for patient with resorption atelectasis Method Breathing pattern… slow, deep breaths with hold at end-inspiration Using prophylactically to prevent atelectasis is not supported

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Contraindications Tension pneumothorax Intracranial pressure (ICP) > 15 mmHg Hemodynamic instability Active hemoptysis Treacheoesophageal fistual Recent esophageal surgery Active untreated tuberculosis Radiographic evidence of blebs Recent facial, oral, or skull surgery Hiccups Air swallowing Nausea

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Hazards & Complications Increased airway resistance Pulmonary barotrauma Nosocomial infection Respiratory alkalosis Hyperoxia (with 02 as source gas) Impaired venous return Gastric distention Air trapping, auto-PEEP, overdistention Psychological dependence

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Administering Desired therapeutic outcomes Spontaneous inspiratory capacity 70% of predicted Improvement of chest x-ray Remission of auscultatory signs of atelectasis (fine, late-inspiratory crackles) Reduce the spontaneous respiratory rate to < 25 /min Potential outcomes Improved inspiratory or vital capacity Increased FEV 1 or peak flow Enhanced cough or secretion clearance Improved chest x-ray, breath sounds, oxygenation Favorable patient subjective response

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Baseline assessment Measurement of vital signs Observational assessment of patient’s appearance & sensorium Breathing pattern and chest auscultation Implementation Infection control… avoid transmission of infection Use proper hand washing Follow CDC universal precautions Follow CDC guidelines for preventing spread of TB Observe all infection control guidelines posted Use only sterile diluents and medications Disinfect all useable equipment between patients Change equipment according to hospital protocol

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Implementation Equipment preparation Make sure equipment is functional Check for patency of patient’s breathing circuit Check for major leaks Occlude mouthpiece aseptically and if system pressure rises and machine cycles off, then the circuit is free of major leaks Patient orientation Explain procedure to patient and why treatment is ordered (layman’s terms) What the treatment does How it will feel What are the expected results

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Patient positioning Semi-fowler’s position or higher Initial application Mouthpiece should be placed well past the lips with tight seal Machine set sensitivity or trigger level of 1-2 cm H20 Machine set pressure of 10-15 cm H20… measure volumes and adjust accordingly Machine set flow to low to moderate flow and adjust accordingly Goal is a breathing pattern of 6 breaths/min with I:E 1:3 to 1:4 ( this will never happen!) Adjust settings according to patient’s response

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Adjusting parameters Pressure and flow individually adjusted Should be volume oriented Volume of 10-15 mL/kg of body weigh 30% of predicted IC Increase in chest expansion with treatment Patient breathe actively during Positive pressure breath Discontinuation/Follow-up Treatment continues until all meds are used up Posttreatment assessment… Vital signs… sensorium… breath sounds…. Recordkeeping… chart according to hospital protocol

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Monitoring Sensitivity Peak pressure Flow setting Fi02 I:E ratio Patient response Breathing rate/expired volume Peak flow or FEV1/FVC% Pulse rate/rhythm(EKG if possible) Sputum color, quantity, consistency,& odor Mental function Skin color Breath sounds, Subjective response

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Lung Expansion Therapy Intermittent Positive Pressure Breathing (IPPB) Troubleshooting Large negative pressure swings early in inspiration Incorrect sensitivity or trigger setting System pressure drops after inspiration Flow too low System pressure increases too fast after inspiration Flow too high Kinked tubing Occluded mouthpiece Active resistance to inhalation Leak in system Machine occurs at connection points or torn exhalation valve Patient interface… loose mouth seal or leaks through nose

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Lung Expansion Therapy Positive Airway Pressure Therapy Definition & Physiological Principle 3 current approaches Positive expiratory pressure (PEP) Expiratory positive airway pressure (EPAP) Continuous positive airway pressure (CPAP) All three are equally effective in treating atelectasis PEP & EPAP used for bronchial hygiene CPAP may be used for oxygenation as well as for treating atelectasis/bronchial hygiene

Lung Expansion Therapy : 

Lung Expansion Therapy PEP Consists of a mask or mouthpiece connected to a one-way breathing valve which creates expiratory resistance The patient breathes in through the inspiratory port and then exhales against expiratory resistance that’s usually set between 10 and 20 cm H2O This keeps the airways open allowing air behind mucus to push it out There are different regimens…it is recommended that the patient take 20-30 breaths, then remove the mask and cough While there is evidence that some patients prefer PEP to other chest physiotherapy methods, there is no evidence to show that it’s more effective than other methods

Lung Expansion Therapy : 

Lung Expansion Therapy EzPAP A mask or mouthpiece is attached to the EzPAP device…oxygen tubing from the EzPAP device attaches to a flowmeter and the flow is adjusted between 5 and 15 lpm (the higher the flow, the more expiratory resistance) Some facilities are using this in lieu of IPPB… the patient breathes through the EzPAP until all the medication is used up

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Lung Expansion Therapy Positive Airway Pressure Therapy CPAP Maintains the same positive airway pressure during both inspiration and expiration PEP/EPAP creates expiratory positive pressure only CPAP Elevates & maintains high alveolar & airway pressure Increases transpulmonary pressure gradient Patient breathes through a pressurized circuit against a threshold resistor with pressures between 5 to 20 cm H20

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Lung Expansion Therapy Positive Airway Pressure Therapy CPAP Factors contributing to its beneficial effect Recruitment of collapsed alveoli causing an increase in FRC Decreased work of breathing due to increased compliance or abolishment of auto-PEEP Improved distribution of ventilation through collateral channels (pores of Kohn/canals of Lambert) Increase in the efficiency of secretion removal

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Lung Expansion Therapy Positive Airway Pressure Therapy CPAP Indications Support of CPAP therapy in atelectasis is documented Duration of beneficial effects appears limited Corresponding increase in FRC lost within 10 minutes after end of treatment Suggest CPAP be used only as continuous, not intermittent basis CPAP by mask used to treat cardiogenic pulmonary edema Reduces venous return and cardiac filling pressures Counters high hydrostatic pressure in pulmonary capillaries Improves compliance Decreases work of breathing

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Lung Expansion Therapy Positive Airway Pressure Therapy CPAP Contraindications Hemodynamically unstable Patient who is having hypoventilation Patient’s with nausea, facial trauma, untreated pneumothorax, & elevated intracranial pressure Hazards/Complications Increased WOB caused by apparatus Baratrauma… especially patients with emphysema & blebs Gastric distention occurs if pressure above 15 cm H20 Leads to vomiting & aspiration

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Lung Expansion Therapy Positive Airway Pressure Therapy CPAP Equipment Gas mixture comes from a blender and flows continuously through a humdifier into the inspiratory limb of the breathing circuit…a reservoir bag provides reserve volume if pt’s inspiratory flow exceeds system Patient breathes in & out of circuit through simple a valveless connector Pressure alarm system with manometer to monitor CPAP pressure at patient’s airway is added to the set-up

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Lung Expansion Therapy Positive Airway Pressure Therapy CPAP Intermittent CPAP Potential Outcomes Improve breath sounds Improve vital signs Resolution of abnormal x-ray findings Restoration of normal oxygenation Monitoring/Troubleshooting Poses real danger of hypoventilation Monitor to indicate loss of pressure due to system disconnect or mechanical failure Common problem… system leaks Tight seal important to maintain pressure > atmospheric Gastric insufflation/aspiration of vomitus

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Lung Expansion Therapy Positive Airway Pressure Therapy CPAP Intermittent CPAP Monitoring Ensure adequate flow to meet patient’s need Flow is initially set 2-3 times the patient’s minute ventilation Flow is adequate when system pressure drops no more than 1-2 cm H20 during inspiration

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Lung Expansion Therapy Positive Airway Pressure Therapy Selecting an Approach Patient must meet criteria for therapy having one or more indications Determine degree of alertness IPPB if VC is 10 -15 mL/kg or <1.0 liter IS or PEP/EPAP therapy indicated with alert patient IS if VC exceeds 15 mL/kg of IBW or IC > 35% predicted Excessive sputum… PEP therapy used instead of IS Bronchodilator therapy may be indicated CPAP used if patient shows no improvement after above therapies have been tried