IPPB part I case studies

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IPPB part Icase studies

• Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

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• Case study 1
• Your patient is a 65 year old WF who just had
  pelvic surgery. She is in traction. To treat her
  effectively, what do you want to assess at this
  point?

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answer

• VS HR is 120 bpm, RR 28 bpm
• LOC she is sleepy and complaining of pain but
  answers appropriately
• Breath sounds diminished basal breath sounds and
  rhonchi and crackles in the upper lobes
• Prior medical history in good health prior to
  this surgery

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• Based on the data you have collected what else
  might you want to see?

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answer

• Sp02 for s/s of respiratory distress Sp02 88
• Inspection for labored breathing and for chest
  wall movement poor chest wall movement, with
  substernal retractions

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• What do you think is wrong with this lady?

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answer

• She is suffering post-op atelectasis and she is
  hypoxic on room air

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• What do you want to do for this patient FIRST?

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• ANSWER
• Start 02 to get her Sp02 above 92

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• After you start her on 2 lpm nasal cannula, you
  see that the Sp02 is still 88. What do you
  suggest to the doctor?

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• You suggest that we raise the Fi02, you might
  also ask for an ABG so we can calculate exactly
  how high to raise the Fi02
• .

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• This is done and you get a Pa02 of 57 torr on 2
  lpm. Where do you want to raise the Fi02, based
  on this new data?

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answer

• Based on Pa02 Fi02 as Pa02 you want Fi02 you
  need, you decide you need a Pa02 80 torr.
• 57 torr .28 as 80 torr X
• 57X .28 (80)
• 57X .28 (80)
• 57
• The Fi02 you need .39
• You suggest entrainment mask at 40

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• After she is put on 40 Fi02 her Sp02 is 95 and
  her respiratory rate drops.
• What do you want to do next?

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• ANSWER
• Start her on IS at 15 ml/kg IBW, assess her
  breath sounds, VS and respiratory effort for
  safety and efficacy of the SMI

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• How would you assess this patient after IS?

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• assess her breath sounds BS are unchanged after
  3 IS TX
• VS HR and respiratory rate continue to stay high
  after IS
• respiratory effort for safety and efficacy of the
  SMI Still with poor chest movement
• She has a weak cough

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• What do you want to assess now in order to treat
  this patient effectively?

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answer

• Look at the X-Ray the atelectasis has spread
  from the one seen on the first day
• What is her IC on the IS? the IC she gets on the
  IS is only 8 ml/kg IBW

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• Based on the information in the last slide, what
  do you want to suggest to the doctor?

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answer

• She needs IPPB at Air/Mix to deliver a Vt of at
  least 15 ml/Kg/ IBW
• The doctor orders 2.5 mg of Albuterol in 2.5 ml
  of normal saline

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• How would you assess the safety effectiveness
  of this therapy?

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answer

• Measure the exhaled Vt to make sure she is
  getting at least 15 ml/Kg IBW and that she is not
  exceeding 45 ml/Kg IBW
• she is getting 25 ml/kg IBW at a pressure of 18
  cmH02
• VS before, 3 minutes into and after IPPB.
• Her HR was 115, rose to 125 in 3 minutes and was
  145 after the IPPB. Her respiratory rate on the
  IPPB is 15 bpm
• Breath sounds before and after IPPB
• Breath sounds increased in basal posterior
• Cough?
• Strong cough with copious, thick green sputum

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• How do you want to modify her TX at this point?

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Answer

• Her Vt is ok
• Her respiratory rate on the IPPB needs to be 6-8
  bpm to give her heart time to refill
• To make sure that Albuterol is not causing the HR
  increase, stop TX after 3 minutes and see if the
  HR decreases back to baseline
• To make the thick secretions thinner, suggest
  Acetylcysteine

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Case study 2

• Your patient is a 55 year old LAM who is 5 8
  tall. He has been admitted for biopsy of the lung
  for possible lung CA cancer
• How do you want to assess this gentleman

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Answer

• prior medical history
• history of working with asbestos
• 20 pack/year smoking history
• Chronic bronchitis for several years
• Inspection for s/s respiratory distress
• Respiratory rate 18 bpm and with no use of
  accessory muscles
• HR 110 bpm
• Breath sounds
• Scattered rhonchi to all lobes and wheezes over
  the RML. A plural rub over the LLL.
• Sp02
• Sp02 is 93 on Room Air
• Sputum production
• Scanty, thick, yellowish sputum

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• What do you suggest to treat him at this point?

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• He doesnt need 02 right now, but he needs a beta
  II bronchodilator and possibly a mucolytic by
  SVN.
• After his surgery, he may need IS so you could
  start him on IS to train him prior to surgery

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• The patient goes to surgery and gets a biopsy
  from his Right Middle Lobar bronchus.
• In recovery room, he is sleepy and you start him
  on IS. He only gets 8 ml/kg IBW
• What do you want to assess right now?

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Answer

• Before you decide to give him IPPB, you need to
  look at his post-op X-Ray to rule out the
  presence of a pneumothorax
• He has no pneumothorax
• You want to check for blood in his sputum
• He coughs up a teaspoon of bloody sputum during
  his IS

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• What do you want to do now?

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Answer

• IPPB is contraindicated in Hemoptysis and he has
  bloody sputum.
• We need continue with the SVN with beta II drug,
  and use segmental breathing,
• but we might have to consider decreasing the
  concentration of the Acetylcysteine from 20 to
  10 add normal saline because Acetylcysteine
  can make bleeding worse by triggering violent
  coughing

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Case study 3

• Your patient is a 45 year old WM who is status
  post s/p multiple trauma from a MVA moving
  vehicular accident
• How do you want to assess this patient?

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Answer

• Check chart for history of current illness
  extent of injuries
• Broken ribs, chest tube placed to drain
  hemothorax.
• VS
• RR 25, HR 118 bpm
• Inspection for s/s of respiratory distress
• Shallow breathing, no retractions, no flaring
• Sp02
• Sp02 91 on 40
• Percussion
• No hyper-resonance over the chest
• BS
• Diminished BS over the LLL area of chest tube
  diminished over RLL. Rhonchi over RUL

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• What else might be assessed?

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answer

• X-ray shows
• LLL effusion, presence of chest tube in the lower
  portion of the chest
• Check history
• no prior cardiopulmonary history
• IBW 65 kg

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• What do you want to treat ?

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answer

• Start supplemental 02 to get the Sp02 above 92
• Initiate coughing, deep breathing
• start IS at a minimal IC of 780-975
• If reassess BS and cough effort after IS to see
  if patient might need mucolytics via SVN

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• After the first IS, the patient can only get 600
  ml, but he is c/o pain on inspiration
• What do you do?

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answer

• Get with nurse regarding his pain medication
  schedule
• Schedule IS to match his pain-free time

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• Patients pain medication is increased and he is
  sleepy and co-operative.
• After three more IS, you note that his IC is
  still only 600 ml.
• What else do you need to assess?

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answer

• His cough effort
• Weak and unproductive
• His VS HR 125 RR 29 bpm
• His BS
• Diminished basal BS
• Rhonchi and crackles over the middle and upper
  lobes
• His X-ray
• The effusion has almost resolved
• Atelectasis in the LLL and the RLL

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• What do you want to do now?

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answer

• Start IPPB at 975 ml to treat atelectasis
• Follow-up X-ray and BS to assess
• Give beta II drug with normal saline
• Follow-up BS and VS to effectiveness and safety