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Lung Expansion Therapy

By Katherine Perez,2014-05-09 20:52
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Lung Expansion Therapy

Lung Expansion Therapy

    Wyka Chapter 18 Page 535

What is Lung Expansion Therapy?

     A group of medical treatment modalities designed to prevent and/or treat pulmonary

    atelectasis and associated problems

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

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

How do we know if someone has an Atelectasis?

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

METHODS USED FOR LUNG EXPANSION THERAPY

     Incentive Spirometry - IS therapy

     IPPB - Intermittent Positive Pressure Breathing CPAP - Continuous Positive Airway Pressure

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

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

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

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.?)

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

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

Example of a Flow-Oriented Device

    See Egan’s Fig 35-4

INTERMITTENT POSITIVE PRESSURE BREATHS (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)

    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

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

Contraindications to IPPB

     Untreated pneumothorax

     High intracranial pressure (>15 mm Hg)

     Active hemoptysis

     Radiographic evidence of a bleb

     Nausea

     Tracheo-esophagel fistula

     Recent esophageal surgery

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!

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)

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

Key Elements of IPPB Instruction

     Explain 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 they have of you

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)

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

Key Aspects & Terms Associated with IPPB ventilators

     Patient initiates the breath and machine is able to detect the patient’s 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)

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)

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

     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)

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

     A simple approach which maintains some positive pressure in the airway at the end

    of exhalation

     Net effect of CPAP is that FRC is increased

     There is a high correlation between improvement of atelectasis and the patient

    having a higher than normal FRC

Review of Lung Volumes & Capacities

Beneficial Effects of CPAP

    ; Recruitment of collapsed alveoli

    ; The work of breathing is decreased as lung compliance (stretchability) improves

    ; Improvement of gas distribution

    ; Improvement in secretion removal

Indications for Use of CPAP

    ; Treatment of post-operative atelectasis

     Should be used continuously

    ; Has been used in the treatment of cardiogenic pulmonary edema

Contraindications to CPAP

    ; If blood pressure is very low

     Diastolic of <50 mm Hg

    ; If patient has one or more of the following;

     Facial trauma (cannot use mask CPAP)

     Nausea

     Untreated pneumothorax

     Elevated intracranial pressure (ICP)

Hazards of the Use of CPAP

    ; Barotrauma (pneumothorax)

    ; Gastric distension

    ; Air-trapping

    ; Decrease in BP

    ; Can be very uncomfortable to the face of patient using mask CPAP

What Does CPAP Accomplish?

    ; Increases the FRC by increasing the amount of air in the chest at the end of

    exhalation

    ; The net effect of increasing FRC is to;

     Re-open any atelectatic areas

     Improve any hypoxemia that may be resulting from the atelectasis

    ; CPAP is also used to treat sleep apnea secondary to upper airway obstruction

End of Section on CPAP

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