Lung Expansion Therapy

1
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 atelectasiscaused 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 signsindirect 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 phasedrop 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 lt 10 mL/kg
• IC lt 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 70s
• Under attack in 80s 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 spacepassive 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) gt 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 lt 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 patients 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 patients 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 (laymans 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-fowlers 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
  IE 13 to 14 ( this will never happen!)
• Adjust settings according to patients 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
• IE 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

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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 thats usually set between 10 and 20
  cm H2O
• This keeps the airways open allowing air behind
  mucus to push it out
• There are different regimensit 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 its more effective
  than other methods

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Lung Expansion Therapy

• EzPAP
• A mask or mouthpiece is attached to the EzPAP
  deviceoxygen 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

23
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
• Patients 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 circuita
  reservoir bag provides reserve volume if pts
  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 patients 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 gt
  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 patients need
• Flow is initially set 2-3 times the patients
  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 lt1.0 liter
• IS or PEP/EPAP therapy indicated with alert
  patient
• IS if VC exceeds 15 mL/kg of IBW or IC gt 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