Volume Expansion Therapy (VET)

1
Volume Expansion Therapy (VET)

• RET 2275
• Respiratory Care Theory 2

2
Volume Expansion Therapy (VET)

• Volume Expansion Therapy
• AKA
• Lung expansion therapy
• Hyperinflation therapy
• A variety or respiratory care modalities
  designed to prevent or correct atelectasis by
  augmenting lung volumes
• Incentive Spirometry (IS)
• Intermittent Positive Airway Pressure (IPPB)
• Continuous Positive Airway Pressure (CPAP)
• Positive Expiratory Pressure (PEP)

3
Volume Expansion Therapy (VET)

• Atelectasis
• Definition alveolar collapse
• Types
• Obstructive
• Caused by mucus plugging of airways
• Passive
• Cause by constant tidal breathing of small
  volumes
• Common complication in postoperative patients

4
Volume Expansion Therapy (VET)

• The Sigh Mechanism
• Definition the automatic, periodic inhalation of
  a large tidal volume to prevent passive
  atelectasis
• Normally, a person sighs about 6-10 times per
  hour
• Passive atelectasis can occur if this mechanism
  is impaired or lost

5
Volume Expansion Therapy (VET)

• The Sigh Mechanism
• Factors that can impair the sigh mechanism
• General anesthesia
• Pain
• Pain medication
• Decreased level of consciousness
• Thoracic or upper abdominal surgery
• Impaired diaphragmatic movement

6
Volume Expansion Therapy (VET)

• Sustained Maximal Inspiration (SMI)
• A slow, deep inhalation form the FRC up to
  (ideally) the total lung capacity, followed by a
  5 10 second breath hold
• Designed to mimic natural sighing
• The negative alveolar pleural pressures
  reexpand collapsed alveoli and prevent the
  collapse of ventilated alveoli

7
Volume Expansion Therapy (VET)

• Indications
• Presence of pulmonary atelectasis
• Presence of condition predisposing to atelectasis
• Upper abdominal surgery
• Thoracic surgery
• Surgery in patient with COPD
• Presence of a restrictive lung defect associated
  with quadriplegia and/or dysfunctional diaphragm

8
Volume Expansion Therapy (VET)

• Contraindications for VET
• Inability of patient to be instructed to perform
  SMI maneuver
• Lack of patient cooperation
• Inability of patient to deep breathe (i.e. VC lt10
  ml/kg)

9
Volume Expansion Therapy (VET)

• Hazards Complications of VET
• Ineffective in absence of correct technique (may
  require repeated instruction coaching)
• Hyperventilation
• Exacerbation of bronchospasm

10
Volume Expansion Therapy (VET)

• Hazards Complications of VET
• Hypoxemia (if O2 therapy is interrupted)
• Barotrauma (in emphysematous lungs)
• Fatigue
• Pain in postoperative patients

11
Volume Expansion Therapy (VET)

• Assessment of Need
• Evidence of atelectasis based on physical exam
  x-ray findings
• Upper abdominal or thoracic surgery
• Presence of predisposing conditions
• Presence of neuromuscular disease affecting the
  respiratory muscles

12
Volume Expansion Therapy (VET)

• Findings Consistent with Atelectasis
• Diminished breath sounds fine crackles in
  affected area
• Fever
• Tachypnea tachycardia
• Dull percussion note
• Characteristic opacity on chest x-ray

13
Volume Expansion Therapy (VET)

• Incentive Spirometry Equipment
• Device is only a visual aid
• Importance is placed on patient performing the
  correct maneuver

14
Volume Expansion Therapy (VET)

• Incentive Spirometry (IS)
• Equipment
• Volume IS

15
Volume Expansion Therapy (VET)

• Incentive Spirometry (IS)
• Equipment
• Flow oriented
• (flow x time volume)

16
Volume Expansion Therapy (VET)

• Incentive Spirometry (IS)
• Administering IS
• Physician order required
• Instruct patient
• Importance of deep breathing
• Demonstration is the most effective way to assist
  the patients understanding and cooperation
• Position patient
• Sitting or semi-Fowlers

Semi-Fowlers Position (Head elevated 30?)
17
Volume Expansion Therapy

• Incentive Spirometry (IS)
• Administering IS
• RT should set initial goal (e.g. certain volume)
• Should require some moderate effort
• Instruct patient to inspire SLOWLY and deeply
• Maximizes distribution of ventilation
• Ensure that the patient is using diaphragmatic
  breathing
• Instruct patient to sustain maximal inspiratory
  volume for 5 10 seconds followed by a normal
  exhalation

18
Volume Expansion Therapy

• Incentive Spirometry (IS)
• Administering IS
• Give the patient an opportunity to rest
• Some patients need 30 seconds to one minute
• Helps prevent hyperventilation, dizziness,
  numbness around the mouth, respiratory alkalosis
• IS regimen should aim to ensure a minimum of 5 -
  10 SMI maneuvers each hour
• Once technique is mastered, minimum supervision
  is required

19
Volume Expansion Therapy (VET)

• Assessment of Outcome
• Absence of or improvement in signs of atelectasis
• Normal respiratory heart rates
• Afebrile
• Absence of abnormal breath sounds

20
Volume Expansion Therapy (VET)

• Assessment of Outcome
• Normal chest x-ray
• Improved oxygenation (PaO2/SpO2)
• Return of normal spirometric values
• Improved respiratory muscle performance

21
Volume Expansion Therapy

• Incentive Spirometry (IS)
• Charting IS
• Pre-treatment vital signs
• HR, RR, Breath sounds
• Initial goal
• Example 800 ml x 10 SMI
• Patient toleration
• Post-treatment vital signs
• Patient education
• See examples of charting notes on next slide

22
Volume Expansion Therapy (VET)

• Incentive Spirometry (IS) - Charting

Example of Chart Note 1/31/06, 0830 IS given
to patient sitting in chair. HR 80 - 72, RR
16 - 14, Breath sounds decreased at bases
bilaterally, some fine crackles noted at end
inspiration. Obtained IS goal of 2.0 L x 7 SMI.
Patient has a dry, non-productive cough. Breath
sounds unchanged after treatment. Patient
tolerated treatment without incident. Example
of Patient Education Note Instructed patient
regarding the importance taking deep breaths
after surgery. Demonstrated IS technique for
patient. Patient verbalized understanding of
therapy and gave a return demonstration with
IS. Sy Big, MDC Student Respiratory Care
23
Volume Expansion Therapy (VET)

• Important Points Regarding Use of IS
• Verify that there is an indication for therapy
• Effective patient teaching coaching is
  essential
• Demonstrate technique for patient
• Teach splinted coughing
• Place device within patients reach
• Provide rest periods as necessary

24
CPAP

• Definition
• The application of a positive airway pressure to
  the spontaneously breathing patient throughout
  the respiratory cycle at pressures of 5 20 cm
  H2O

25
CPAP

• Physiological Principles
• CPAP elevates and maintains high alveolar and
  airway pressures throughout the full breathing
  cycle.

26
CPAP

• Physiologic Principles - Equipment
• The patient on CPAP breaths through a pressurized
  circuit against a threshold resistor, with
  pressures maintained between 5 20 cm H2O

27
CPAP

• Physiologic Principles - Equipment

28
CPAP

• Physiologic Principles
• CPAP
• Recruits collapsed alveoli via an increase in FRC

29
CPAP

• Physiologic Principles
• CPAP
• Recruits collapsed alveoli via an increase in FRC
• Decreases work of breathing due to increased
  compliance or abolition of auto-PEEP
• Improves distribution of ventilation through
  collateral channels (e.g., Kohns pores)
• Increases the efficiency of secretion removal

30
CPAP

• Indications
• Postoperative atelectasis
• Cardiogenic pulmonary edema
• Refractory hypoxemia
• PaO2 lt60 mm Hg, SaO2 lt90 on an FiO2 gt0.40 0.50
  in the presence of adequate ventilatory status
  (PaCO2 lt45 mm Hg, pH 7.35 7.45)
• Obstructive sleep apnea

31
CPAP

• Contraindications
• Hemodynamic instability
• Hypoventilation
• CPAP does not ensure ventilation
• Nausea
• Facial trauma
• Untreated pneumothorax
• Elevated intracranial pressure

32
CPAP

• Hazards and Complications
• Increased work of breathing caused by the
  apparatus
• Hypoventilation and hypercapnia
• Patients with ventilatory insufficiency may
  hypoventilate during application
• Barotrauma
• More likely in patients with emphysema and blebs
• Gastric distention (CPAP pressures gt15 cm H2O)
• Vomiting and aspiration in patients with an
  inadequate gag reflex

33
CPAP

• Monitoring and Troubleshooting
• Patients must be able to maintain adequate
  excretion of CO2 on their own
• System pressure must be monitored
• Alarms need to indicate system disconnect or
  mechanical failure
• Masks may cause irritation and pain
• Adequate flow to meet patients need
• Flow initially set to 2 3 times the patients
  minute ventilation
• Flow is adequate when the system pressure drops
  no more than 1 2 cm H2O during inspiration

34
CPAP

• Patient Interfaces
• Nasal Mask

35
CPAP

• Patient Interfaces
• Fitting the Nasal Mask
• Dorsum of nasal bridge
• Around the nasal alae
• Mid philtrum
• Use foam bridge
• Prevents collapse of mask
• onto nose

36
CPAP

• Patient Interfaces
• Fitting the Nasal Mask
• DO NOT over tighten
• Tissue necrosis

37
CPAP Tissue necrosis
38
CPAP

• Patient Interfaces
• Full-Face Mask

39
CPAP

• Patient Interfaces
• Fitting the Full-Face Mask
• Dorum of nasal bridge
• Surrounds nose/mouth
• Rests below lower lip
• DO NOT over tighten
• Tissue necrosis
• Foam bridge
• Prevents collapse of mask
• onto nose

40
CPAP

• Nasal vs. Full-Face Mask
• Nasal Masks
• More prone to air leaks (especially mouth
  breathers)
• Use chin strap
• Full-Face Mask
• Increase dead space
• Risk of aspiration
• Claustrophobia
• Interferes with expectoration of secretions,
  communication, eating

41
CPAP

• Patient Interfaces
• Total Face Mask

42
EZ-PAP

• Lung expansion therapy during inspiration and PEP
  therapy during exhalation
• Used for the treatment or prevention of
  atelectasis and the mobilization of secretions
• Aerosol drug therapy may be added to a PEP
  session to improve the efficacy of bronchodilator

43
EZ-PAP

• EZ-PAP

44
EZ-PAP
45
EZ-PAP with SVN
46
IPPB

• Definition
• The application of inspiratory positive pressure
  to a spontaneously breathing patient as an
  intermittent or short-term therapeutic modality

47
IPPB

• Definition
• The delivery of a slow deep sustained inspiration
  by a mechanical device providing controlled
  positive pressure breath during inspiration

48
IPPB

• Indications (AARC)
• The need to improve lung expansion
• Treatment of atelectasis not responsive to other
  therapies, (e.g., IS and CPT)
• Inability to clear secretions adequately
• Limited ventilation
• Ineffective cough

49
IPPB

• Indications (AARC)
• Short-term nonivasive ventilatory support for
  hypercapnic patients
• Alternative to intubation and continuous
  ventilatory support

50
IPPB

• Indications (AARC)
• The need to deliver aerosol medication
• When MDI or nebulizer has been unsuccessful
• Patients with ventilatory muscle weakness or
  fatigue

51
IPPB

• Contraindications (AARC)
• Tension pneumothorax
• ________________________________________
• ICP gt 15 mm Hg
• Hemodynamic instability
• Recent facial, oral or skull surgery

52
IPPB

• Contraindications (AARC)
• Tracheoesophageal fistula
• Recent esophageal surgery
• Active hemoptysis
• Nausea
• Air swallowing

53
IPPB

• Contraindications (AARC)
• Active, untreated TB
• Radiographic evidence of bleb
• Singulus (hiccups)

54
IPPB

• Hazards (AARC)
• Increase airway resistance (Raw)
• Barotrauma, pneumothorax
• Nosocomial infection
• Hyperventilation (hypocapnia)
• Hemoptysis

55
IPPB

• Hazards (AARC)
• Hyperoxia when O2 is the gas source
• Gastric distention
• Secretion impaction (inadequate humidity)
• Psychological dependence
• Impedance of venous return

56
IPPB

• Hazards (AARC)
• Exacerbation of hypoxemia
• Hypoventilation
• Increased V/Q mismatch
• Air trapping, auto peep, overdistended alveoli

57
IPPB

• Potential Outcomes
• Improved IC or VC
• Increased FEV1 or peak flow
• Enhanced cough or secretion clearance
• Improved Chest radiograph
• Improved breath sounds

58
IPPB

• Potential Outcomes
• Improved oxygenation
• Favorable patient subjective response

59
IPPB

• Baseline Assessment
• Vital signs
• Patients appearance and sensorium
• Breathing pattern
• Breath sounds

60
IPPB

• Implementation
• Infection control
• Equipment preparation
• Pressure check machine/circuit
• Patient orientation
• Why MD ordered therapy
• What treatment does
• How it feels
• Expected results

61
IPPB

• Implementation
• Application
• Mouthpiece / nose clip (initially)
• Mouthseal
• Mask
• Trach adaptor

62
IPPB

• Implementation
• Machine settings
• Sensitivity of 1 2 cm H2O
• Initial pressure between 10 15 cm H20
• Breathing pattern of 6 breaths/min
• IE ration of 13 to 14
• Flow and pressure will need subsequent adjustment
  to patients needs and goal

63
IPPB

• Implementation
• When treating atelectasis
• Therapy should be volume-oriented
• Tidal volumes (VT) must be measured
• VT goals must be set
• VT goal of 10 15 mL/kg of body weight
• Pressure can be increased to reach VT goal if
  tolerated by patient

64
IPPB

• Implementation
• When treating atelectasis
• IPPB is only useful in the treatment of
  atelectasis if the volumes delivered exceeds
  those volumes achieved by the patients
  spontaneous efforts

65
IPPB

• Discontinuation and Follow-Up
• Treatments typically last 15-20 minutes
• Repeat patient assessment
• Identify untoward effects
• Evaluate progress
• Document