RT 210

1
RT 210

• Lung Expansion /
• Hyperinflation TX

2
Sustained Maximal Inhalation/Incentive Spirometry
SMI/IS

• Indications
• To improve atelectasis
• To prevent atelectasis
• Post-op
• COPD
• Other pulmonary complications
• Mobilize secretions

3
Sustained Maximal Inhalation/Incentive Spirometry
SMI/IS

• Contraindications
• Patient unable to cooperate
• Patient unable to follow instructions
• Patient unconscious
• Patient unable to take deep breaths

4
Sustained Maximal Inhalation/Incentive Spirometry
SMI/IS

• Hazards
• Ineffective unless performed correctly
• Hyperventilation
• Barotrauma
• Discomfort secondary to pain
• Fatigue

5
Sustained Maximal Inhalation/Incentive Spirometry
SMI/IS

• Procedure
• Slow deep inspiration
• Inspiratory hold
• Relaxed exhalation
• Volume of gas moved should be inspiratory
  capacity
• Maximum inhalation following a quiet exhalation

6
Sustained Maximal Inhalation/Incentive Spirometry
SMI/IS

• Procedure (cont)
• Coaching the patient is important
• Encouragement
• Insure proper technique
• Frequency
• May be performed by patient after instruction
• Q 1 hour while awake
• Follow-up daily or PRN

7
Sustained Maximal Inhalation/Incentive Spirometry
SMI/IS

• Equipment
• Most actually measure flow and time
• Triflow
• InspiRx
• Some measure volume
• Bartlett Edwards (Bellows)
• Inspiron (Vortex Principle)

8
Sustained Maximal Inhalation/Incentive Spirometry
SMI/IS

• Patient Evaluation
• Alert
• Cooperative
• Physically able to increase IC greater than VT
• Should be 3 times predicted VT

9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
IPPB

• Intermitent Positive Pressure Breathing

14
IPPB Indications

• Primary
• If patient has inadequate VC to facilitate a
  cough, VC less than 3 times predicted VT then VC
  less than 15ml/kg of ideal body weight

15
IPPB Indications

• Secondary
• To deliver medication
• Improve IE ratio
• Improve cough and mobilize secretions
• Alter V/Q
• To improve or prevent atelectasis
• To decrease CO2 temporarily

16
Contraindications of IPPB

• Absolute
• An untreated closed pneumothorax

17
Contraindications of IPPB

• Secondary Contraindications
• ICP gt 15mmHg
• Hemodynamic instability
• Recent facial, oral, or skull surgery
• Tracheal-esophageal fistula
• Active hemoptysis
• Active TB
• Blebs or bullae

18
Contraindications of IPPB

• Hazards/Complications
• Barotrauma - pneumothorax
• Nosocomial infection
• Hypocarbia
• Hyperoxia
• Tachypnea
• Gastric distension
• Impedance of venous return
• Air trapping

19
Contraindications of IPPB

• Hazards/Complications (cont)
• Increased ICP
• O2 induced hypoventilation in COPD patients
• Decreased cardiac output
• May cause or worsen hemoptysis

20
Contraindications of IPPB

• Hazards/Complications (cont)
• Hyperventilation
• Dizziness
• Loss of consciousness
• Tetany
• Paresthesia Decreased cerebrovascular PCO2
  during hyperventilation causes vasoconstriction
  and decreased cerebral blood flow

21
Physiologic Effects of IPPB

• Increased intrapulmonary pressure
• Decreased venous return, worsened by increasing
  inspiratory time
• May decrease cardiac output
• Mechanical bronchodilation
• Altered IE ratio

22
Physiologic Effects of IPPB

• Altered V/Q ratio
• Mobilization of secretions
• Generally increased PaO2 and decreased PaCO2
• Decreased work of breathing

23
Administration of IPPB

• Demonstrate set-up
• Check for leaks
• Patient instruction
• Passive treatment
• Slow deep inspiration with hold
• Maintain seal
• Explain nature of and expected results of Rx
• Rx should be gentle start to inhalation, with
  slow, deep breath, followed by passive exhalation

24
Administration of IPPB

• Coaching patient
• Calm and reassure patient/relaxation
• Verbally instruct in timing of inspiration and
  expiration
• Total relaxed exhalation

25
Administration of IPPB

• Monitoring patient
• Breath sounds
• VT (3 times predicted VT)
• Respiratory rate
• Pulse Stop Rx when increased by 20 BPM
• Verbal response
• Ask subjective responses
• Dizziness
• Tingling

26
PAP

• Define Physiologic Principles
• Indications
• Contraindications
• Hazards complications of CPAP (Egan mini
  clinic)
• Equipment
• Administer Intermittent CPAP
• Monitoring and Troubleshooting

27
Bird Mark 7 8 (10 14)

• Classification
• Positive pressure ventilator forces air into
  lungs
• Pneumatically powered doesn't require electricity
  (gas powered)
• Pneumatically driven
• It's regulator is like a gauge regulators
• Pneumatically driven ceramic switch
• Single circuited the same gas supply goes to the
  patient that powers the machine

28
Bird Mark 7 8 (10 14)

• Modes
• Assist
• The only mode used for IPPB
• Patient sets rate, then machine delivers rate
• Assist Control
• Used for continuous ventilation
• If patient fails to set rate, machine will
  deliver preset rate
• Control machine set rate and does not allow
  patient to alter preset pattern

29
Bird Mark 7 8 (10 14)

• Pressure cycled
• Cycling is what ends inspiration
• When set pressure is reached, machine ends
  inspiration
• Other possibilities of cycling
• Flow
• Time
• Volume
• Flow limit - can be set

30
Bird Mark 7 8 (10 14)

• Flow pattern
• Determined by 100 or air mix setting due to
  effects of back pressure on the Venturi gate
• 100 - square wave, flow remains constant in the
  face of back pressure - "flow generator"
• Air mix - decaying flow curve due to partial
  closure of Venturi gate
• Due to back pressure, flow decreases as pressure
  increases

31
Bird Mark 7 8 (10 14)

• Pressure pattern
• Determined by flow pattern
• 100 source gas rectilinear
• Air mix parabolic

32
Bird Mark 7 8 (10 14)

• Internal resistance
• How the flow curve is effected by back pressure
• Air mix low
• flow pattern is much effected by back pressure

33
Bird Mark 7 8 (10 14)

• Principles of Operation
• Magnetism versus gas pressure
• Two chambers of machine divided by a diaphragm
• Left side same as atmospheric pressure
• Right side - same as system pressure

34
Bird Mark 7 8 (10 14)

• On inspiration, diaphragm is drawn to the right
  by decreased system pressure when patient
  initiates a breath
• As pressure builds up on pressure side, the
  diaphragm is pushed back to the left over-coming
  pressure of the magnetic pull of the switch plate
• A ceramic switch is moved by diaphragm which
  turns gas flow on and off

35
Bird Mark 7 8 (10 14)

• Specifications
• Flow is variable and adjustable
• Peak flows on 100 0-50 LPM
• Peak flow on air mix 0-80 LPM
• Venturi gate
• Open -2 cm H2O
• Closes at 2cms H2O lower (Venturi gate spring
  resistance) then peak or set pressure

36
Bird Mark 7 8 (10 14)

• Air Mix controller
• Determines 100 source gas or air mix
• Air mix
• If O2 is the source gas, FIO2 will be 0.4 to 0.8
• The machine functions as a pressure generator
• 100
• FIO2 will be FIO2 of source gas
• The machine functions as a flow generator

37
Bird Mark 7 8 (10 14)

• Nebulizer drive
• Nonadjustable
• FIO2 will be FIO2 of source gas
• Breaks off gas flow before Venturi
• Pressure
• Located on right side of ventilator
• Adjustable 0-60 cmH2O (Mark-7, 8, 10)
• In mmHg Mark-14
• The closer the magnet to the clutch plate the
  higher the pressure required to cycle

38
Bird Mark 7 8 (10 14)

• Sensitivity
• Adjustable on ambient (left) side of machine
• The closer the clutch plate to the magnet, the
  less sensitive or more pressure required to
  initiate inspiration
• Apnea Timer
• Works off of a small leak altering pressure
  internally
• Allows machine to be used for A/C or control
  modes
• Not used for routine IPPB

39
Bird Mark 7 8 (10 14)

• Bird Mark 8
• Has negative expiratory pressure capabilities
• Used Q circuit set-up
• Not normally used for IPPB

40
Bird Mark 7 8 (10 14)

• Bird Mark 10
• Has flow accelerator
• Increases flow at end inspiration to compensate
  for leaks

41
Bird Mark 7 8 (10 14)

• Bird Mark 14
• Has higher pressure capabilities, flow
  accelerator
• No negative pressure

42
Bird Mark 7 8 (10 14)

• Circuit
• Large bore tubing
• Side stream or mainstream
• Exhalation valve
• One small bore tubing with "Y" to allow delivery
  to exhalation valve and nebulizer
• Mouthpiece, mask or trachea adaptor

43
Bennett Ventilators Classification

• Positive pressure
• Pneumatically powered
• AP series is electrical
• Pneumatically driven Bennett Valve
• Single circuited
• Modes
• Assist only for IPPB
• Assist/Control not for IPPB treatments

44
Bennett Ventilators Classification

• Flow cycled
• Pressure causes flow to drop to 1-3 LPM and ends
  inspiration
• PR-2 can be time cycled
• Pressure limited Preset control pressure
• Decaying flow pattern
• Parabolic pressure pattern
• Low internal resistance back pressure greatly
  influences flow pattern

45
Bennett Ventilators ClassificationMethod of
Operation

• Bennett valve - a counter balanced drum with
  vanes and windows allowing rotation to permit
  flow through the windows or to stop it
• Sensitivity
• Adjustment to regulate patient effort
• Set as sensitive as possible to insure minimal
  patient effort
• Less than -2cm H2O for assist mode
• Nebulization
• Is off air dilution
• May be continuous or intermittent
• Adjustable

46
Bennett Ventilators ClassificationMethod of
Operation

• Circuit setup
• Large bore tubing
• Nebulizer
• Adaptor to patient
• Expiratory valve
• 2 small bore tubes - one for expiratory valve and
  other for nebulization

47
Description of Bennett Models

• AP-4 5
• Electrically powered
• Compressor driven
• Flow sensitive
• Flow cycled (1-2 LPM)
• Single circuit
• Assistor only
• Pressure limited
• Low internal resistance
• Decaying flow pattern
• Parabolic pressure pattern

48
Description of Bennett Models

• Venturi models - PR-1, PR-2
• Knob in - room air entrained
• Knob out - 100 source gas
• Flow/Pres. characteristics same for both setting
• Air mix delivers FIO2 above 0.40

49
Description of Bennett Models

• PR-1
• No Adjustment of peak flow
• No negative pressure
• No terminal flow (like flow accelerator on Bird)
  to compensate for leaks

50
Description of Bennett Models

• PR-2
• Has terminal flow
• Peak flow decelerator
• Negative pressure

51
Description of Bennett Models

• AP Series
• Same Bennett valve
• Electrically compressor driven
• Used for home care frequently

52
General Considerations For IPPB Therapeutic Units

• Increasing pressure will increase volume
  delivered and IE ratio
• Increasing flow rate will decrease inspiratory
  time and decrease IE ratio
• Increasing sensitivity is desirable unless
  autocycle occurs
• Rate control is not used during IPPB (pure assist
  mode)

53
(No Transcript)
54
General Considerations For IPPB Therapeutic Units

• Nebulizer should be adjusted to create optimum
  aerosol production without wasting medication
• Initial volume/pressure relationship is based
  upon normal compliance value, and adjusted
  according to patient response and therapeutic
  goals

55
IPPB Lab (not notes)

• Check chart
• History
• Physical
• Orders
• Lab results
• Complications
• Find the proper patient
• Identify yourself
• Ask the patient, "Are you Mr. or Ms.
  ___________?"
• Check the patient's arm band

• Set up the equipment
• Plug in the power source
• Attach all parts needed
• Check all settings
• Addition of medications
• Proper/appropriate medication checked
• Draw up and instill in nebulizer
• Assure proper nebulizer action

56
IPPB Lab (not notes)

• Starting the treatment
• Check the patient's name tag again
• Hand nebulizer to the patient
• Instruct the patient in lay terms
• Set inspiratory peak flow setting
• 1/4 to 1/2 turn of knob
• use lower flows for new starts
• Have patient start breathing on circuit
• Assure seal around mouth piece or mask
• Assure proper adjustments of settings
• Proper flowrate IE less then 12
• O2/Air mix

• Proper instruction and/or coaching of patient
• Modification for patient
• Seal-mp., mask, mouth seal
• Control of rate
• Ventilatory pattern
• Adverse effects
• Pulse monitored
• Observation
• Patient interview
• Return Demonstration
• Vary machines
• Birds
• Bennett
• Vary delivery device
• Vary orders

57
IPPB Lab (not notes)

• Trouble shoot patient problems
• Hyperventilation
• Tachycardia
• Dyspnea
• Tingling of fingers
• Diaphoresis
• Bradycardia
• Frank bloody production