Lung Expansion Therapy Part 1

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Lung Expansion Therapy Part 1

• By Jim Clarke

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What is Lung Expansion Therapy?

• A group of medical treatment modalities designed
  to prevent and/or treat pulmonary atelectasis and
  associated problems

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Causes Types of Atelectasis

• Resorption atelectasis
• a blockage occurs in the airway- preventing
  ventilation downstream - resulting in eventual
  removal of remaining gas alveolar collapse
• Passive atelectasis-
• Occurs when patients do not take periodic deep
  breaths (sighs)
• Compressive atelectasis
• Occurs when something outside the lung presses on
  lung tissue causing it to collapse

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What Patients Are at-risk for Atelectasis

• Post-op thoracic or abdominal surgery patients
• Any heavily sedated patient
• Patients who have neuromuscular diseases
• These diseases may weaken breathing muscles
• Patients who are unable to ambulate
• Patients with chest trauma or chest wall injury

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How do we know if someone has an Atelectasis?

• Gold Standard - evidence of atelectasis on a
  chest x-ray (CXR)

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Example of Upper Lobe Atelectasis
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Methods Used for Lung Expansion Therapy

• Incentive Spirometry - IS therapy
• IPPB - Intermittent Positive Pressure Breathing
• CPAP - Continuous Positive Airway Pressure

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Incentive Spirometry

• Used primarily as a preventative or prophylactic
  treatment
• Patient are encouraged to take slow - deep
  inspirations ten times every hour
• Patients are taught to perform 5-10 second breath
  holds at maximal inhalation for each of the 10
  hourly breaths

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Advantages of I.S. Therapy

• Patients can self-administer as often as they
  like
• Relatively easy to learn and perform
• Very rare side effects
• Inexpensive way of preventing pulmonary
  complications

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Reasons Why I.S. May Not Be Appropriate

• Patient is not alert or cannot follow
  instructions
• Patient cannot hold mouthpiece in their mouth
• Patient has a large atelectasis that must be
  treated with more aggressive measures
• Patient cannot create a large enough breath for
  I.S. to be of any real value

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Prior to Teaching I.S. do the following

• Check the chart for
• Order Admitting Dx evidence of any recent
  surgery (when? type?) evidence of any previous
  pulmonary problems (COPD asthma?) Chest X-ray
  reports
• At the bedside check for
• mental status ability to comprehend pain level
  evidence of any pulmonary problems (tachypnea
  /or S.O.B.?)

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What to Focus on During I.S. Instruction

• What is I.S.
• Why is the patient going to learn how to perform
  it
• How often should the patient perform it
• Does the patient have any questions

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Types of I.S. Devices

• Volume Oriented devices
• Actually measure display the amount of air
  patient inhaled
• Flow Oriented devices
• Only display inspiratory flowrate and may attempt
  to estimate amount of air inhaled

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Examples of Two Electronic I.S. Devices
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Example of a Flow-Oriented Device

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IPPB as Method of Enhancing Lung Expansion

• Definition - Lung expansion therapy utilizing
  positive airway pressure for periods of 15 - 25
  minutes to enhance resting lung ventilation by
  increasing the patients tidal volume (Vt)

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How Positive Pressure Ventilation Differs from
Normal

• In normal breathing, inspiratory pressures are
  negative while expiratory pressure are positive
• In IPPB, both inspiratory pressures expiratory
  pressure are positive

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How Pressures Change During Inspiration
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Indications For IPPB

• Patient has an atelectasis that is not responding
  to I.S. therapy
• Patient cannot perform I.S. therapy
• This may also be a problem with IPPB!!
• Poor cough effort secretion clearance due to
  inability to take a deep breath
• Short term ventilatory support when patient is
  hypercapnic
• Enhancement of aerosol medication delivery in
  patient unable to take a deep breath

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Contraindications to IPPB

• Untreated pneumothorax
• High intracranial pressure (gt15 mm Hg)
• Active hemoptysis
• Radiographic evidence of a bleb
• Nausea
• Tracheo-esophagel fistula
• Recent esophageal surgery

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Hazards Complications of IPPB

• Barotrauma (pneumothorax)
• Hyperventilation (dizziness)
• Gastric distension (secondary to air swallowing)
• Decrease in venous return (possible drop in B.P.)
• Increased airway resistance
• May actually cause bronchospasm in some patients!

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Monitoring the IPPB Treatment

• What is the pulse respiratory rate prior to
  treatment?
• What are the patients breath sounds their color
  respiratory effort mental state - prior to the
  Tx?
• What is the patients SpO2 or peakflow before the
  treatment (if giving bronchodilators)

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Equipment Needed for IPPB

• IPPB Ventilator -
• Bennett PR series ventilator OR Bird Mark
  series ventilator
• IPPB tubing circuit
• Universal disposable circuits now used
• Additional equipment possibly needed
• Mouthseal noseclips for patients who cannot use
  mouthpiece
• Mask (if mouthseal is not available)
• Connector for using circuit with trach patient

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Key Elements of IPPB Instruction

• What is IPPB
• Why is the patient going to be receiving IPPB
  treatments
• How long is each treatment how often will they
  receive it
• What should they do during the treatment
• Any questions

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What should the patient do during IPPB?

• Patient starts their breath the machine cycles
  on
• Patient relaxes and lets the machine fill their
  lungs
• Patient should NOT be actively breathing after
  the machine cycles (turns on)
• Patient will exhale normally in a relaxed way
  through the mouth when machine ends inspiration
  (pre-set pressure is reached)

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What should the therapist emphasize during the
treatment?

• Make sure patients keep lips sealed tight around
  the mouthpiece
• Coach patient to not actively breath
• Relax and let the machine fill your lungs!
• Make sure patient does not breath too rapidly
  during treatment
• This will cause dizziness secondary to
  hyperventilation

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Key Aspects Terms Associated with IPPB
ventilators

• Patient initiates the breath and machine is able
  to detect the patients effort and then starts
  delivering gas into the mouthpiece
• The ability of machine to detect the patients
  need for a breath is called sensitivity
• Sensitivity should be set so that machine will
  begin breath at a pressure that is 1 or 2 cmH2O
  pressure below zero (or -1 to -2 cmH2O pressure)

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These machines are pressure cycled

• This means that inspiration ends when a preset
  pressure is reached in the circuit
• Preset pressure is set by the therapist
• Typical pressure ranges (15 - 25 cmH2O)
• Pressures higher than 25 associated with air
  swallowing particularly with mouthseal or mask
  treatments
• Pressures less than 15 may be insufficient to
  increase the tidal volume (Vt)

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Characteristics of Pressure Cycling

• Any leak in the circuit or in the patient will
  cause the machine to not end inspiration (cycle
  off)
• Patient can easily end the breath by
• blowing back into the mouthpiece
• putting their tongue over the mouthpiece
• Pressure cycled machine can NOT guaranteed to
  deliver any specific volume to the patient

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Characteristics of Pressure Cycling

• Volume delivered is based upon
• the patients ability to relax and let the
  machine deliver the breath
• the pressure level set by the therapist
• the higher the pressure level set - the greater
  the volume delivered to the patient (ideally)

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End of Week 2 - Thursday