HyperinflationSecretion Mgmt

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Hyperinflation/Secretion Mgmt
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Purpose of Hyperinflation

• To facilitate lung expansion by a transpulmonary
  pressure gradient (PL)
• PL Palv - Ppl
• Increasing Palv through PPV
• Decreasing Ppl through inspiration

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IPPB

• IPPB is a positive pressure device that augments
  lung inflation by increasing alveolar lung
  pressures (Palv)
• It is pressure limited, pressure cycled
• Used 1o on spontaneously breathing pts
• Given by mouth piece or face mask

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IPPB

• Goals
• To improve lung expansion
• ?TV at least 10-15 cc/kg of IBW
• To mobilize retained secretions
• Improve and promote cough
• To provide short term ventilatory support
• To improve ventilation (?PaCO2)
• Improve distribution of ventilation
• To deliver aerosolized medications

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IPPB

• Indications
• VC lt 10-15 cc/kg IBW
• S/P (post-operative) w/atelectasis
• Weak, npc and poor inspiratory efforts
• Acute alveolar hypoventilation
• Myasthenia gravis (resp. muscle fatigue)
• Drug induced respiratory depression
• Delivering aerosolized medications to pts unable
  to use MDI or SVN

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IPPB

• Contraindications
• Untreated tension pneumothorax
• ? ICP
• Hemodynamic instability
• Recent facial, oral, skull Sx or trauma
• Tracheoesophageal (T-E) fistula
• Active hemoptysis
• Nausea

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IPPB

• Physiological effects
• ?mean airway pressure
• ?WOB
• Altered IE ratio
• ?TV
• Mobilization of secretions
• ?PaO2 and ?PaCO2
• Mechanical bronchodilitation
• ?distribution of ventilation

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IPPB

• Hazards/complications
• Barotrauma ? pneumothorax
• Gastric insufflation
• Dizziness
• Paresthesia
• Dyspnea
• Emesis
• Hyperventilation (PaCO2 lt 35 mmHg)

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IPPB

• Hazards/complications
• Hemoptysis
• Hyperoxia
• ?hypoxic drive (O2 induced alveolar hypovent)
• Psychological dependence
• ?BP ? ?CO
• ?venous return
• ?air trapping

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IPPB

• Assessment of outcome
• TV at least 2x that of spontaneous efforts
• Improved PF and FEV1
• Improved cough
• Improved lung sounds
• Positive pt response to Rx
• Clearing of infiltrates on chest x-ray

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IPPB

• Monitoring
• HR, RR, BP, TV
• For pain, e.g. Grimacing
• Secretion production
• Quantity, color, consistency, odor
• Sensorium
• Skin color
• SpO2

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IPPB

• Initial Settings
• Inspiratory pressure
• 15-20 cm H2O
• Inspiratory flow
• 15-20 lpm
• Sensitivity
• 15-20 cm H2O

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IPPB

• Adjusting Settings
• Inspiratory pressure
• Use the lowest amount of pressure to ?TV
• Use the highest amount of pressure that the pt
  can tolerate to expand lungs and improve cough
• Monitor for pt discomfort
• Pt should NOT have to blow against the flow to
  shut cycle the device
• Instruct pt to relax and breath with the device

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IPPB

• Inspiratory flow
• Adjust enough flow so that the pressure manometer
  needle does not start negative then suddenly
  positive
• Pt is inspiring at a greater inspiratory flow
  than what is provided, so the needle will deflect
  negative

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IPPB

• Sensitivity
• Adjust the sensitivity until the needle deflects
  no more than (-2) cm H20 on inspiration

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IPPB

• Pearls
• Inspiratory pressure and flow can alter IE ratio
  by ? or ?inspiratory time (TI)
• The longer the TI the greater the TV
• Most COPD pts prefer faster flows
• The use of accessory muscles ? short TI
  longer TE
• Coaching and proper instruction is the KEY
• Sensitivity is the trigger
• If the needle deflects towards negative, ?flow