device that supplies positive pressure to the airways following a patient inspiratory effort
IPPB
spontaneous ventilation - Boyle's law states that at a constant _________, pressure and volume are directly related
temperature
goals of IPPB therapy
promote an effective cough, mobilize secretions, improve distribution of ventilation, delivery of medication
indications for IPPB therapy
acute hypoventilation, chronic hypoventilation, weaning, atelectasis, clearance of secretions, acute respiratory distress, aerosol therapy, placebo effect
primary indication for IPPB
VC < 10 ml/kg
contraindications for IPPB
acute pneumothorax being managed without a chest tube, pneumothorax with a chest tube, history of a pneumothorax, sub-q or mediastinal emphysema, tracheoesophageal fistula, inadequate facilities, Bollous disease, cardiovascular insufficiency, availability
all contraindications for IPPB are _______
relative
weakened out pouching of the alveoli
Bollous disease
an erosion between trachea and esophagus
treacheoesophageal fistula (T.E. fistula)
hazards of IPPB: pulmonary effects
hyperinflation and pulmonary edema
hyperinflation is in patients that are prone to ______
air trapping
hyperinflation causes ______ and _______ in the chest
dyspnea and discomfort
if your patient stops the IPPB treatment, begins coughing, then complains of chest pain and SOB, assess for a ___________
pneumothorax
hyperinflation may cause pneamothorax or _______
weakened out pouching in the alveoli
very high pressures can lead to ______
pulmonary edema
hazards of IPPB therapy: circulatory effects
-decreased venous return
-physical disturbance of the heart
-changes in the fluid balance
decreased venous return is caused by
increased thoracic pressure
decreased venous return can cause what two things
hypotension and increased intracranial pressure
physical disturbance of the heart may be caused by
pressure or the medication being given and may include arrhythmias and coronary insufficiency
changes in the fluid balance: the patient may have increased fluid excretion or fluid retention causing ________
electrolyte imbalances
hazards of IPPB: gastrointestinal effects
-gastric insufflations (swallowing air)
-abdominal distention (from swallowing air)
-nausea, vomiting, and pulmonary aspiration
hazards of IPPB: effects on blood gases
-hypoventilation (if the pressures aren't set appropriately)
-hyperventilation (if the pressure is set too high or the oxygen level isn't set appropriately; if the patient is being over ventilated, they will experience dizziness, light headedness, and tin
hazards of IPPB: general side effects
-patient may become claustrophobic or distressed
-they may not relax and may fight the machine (this will increase the work of breathing and result in increased dyspnea, increased work of breathing and deterioration of blood gases and pulmonary functions)
hazards of IPPB: adverse side effects of medication - NEVER give a ______ IPPB (need medication in there, not just saline. Just saline will cause bronchospasm and will dry out mucosa)
dry
effects of IPPB: increase Pao2 - how it works
-increases tidal volume, allowing greater surface area
-improves the ventilation of low compliance lung units
-we can provide supplemental oxygen while giving treatment
why not to use IPPB to increase Pao2
-simple oxygen administration with a cannula or mask may give the same level of oxygenation
-hyper-oxygenation may cause depression of the hypoxic drive to breathe in CO2 retainers
-the Fio2 cannot be accurately controlled
-increasing the Pao2 for a few m
normal TLC
6000 ml
normal VC
4800 ml
normal RV
1200 ml
normal IC
3600 ml
normal FRC
2400 ml
normal IRV
3100 ml
normal VT
500 ml
normal ERV
1200 ml
how IPPB decreases Paco2
-increases ventilation
-improves ventilation of low compliance
-decreases work of breathing
why not to use IPPB to decrease Paco2
-over ventilation can result in respiratory alkalosis
-simple methods involving deep breathing may be equally effective
-lowering the PaCO2 may not occur unless the tidal volume is increased
how IPPB improves clearance of secretions
-through ventilation of partially obstructed lung units
-loosening of adherent secretions
-stimulation of a cough
-delivery of aerosols and humidity
why not to use IPPB to improve clearance of secretions
-there are more simple methods that work adequately without IPPB
-loosened secretions may move distally and cause worsening of the ventilation/perfusion causing decreased Pao2
-IPPB and aerosol drugs may cause bronchorrhea
-IPPB with dry gas can cause dry
how IPPB prevents or treats atelectasis
-through ventilation of atelectatic units directly and through collateral circulation (Pores of Kohn and Isles of Lambert)
-loosening of secretions and stimulation of a cough
-allows increased tidal volume without pain in the post-op patient
why not to use IPPB to prevent or treat atelectasis
-other more simple methods are as good or better
-bronchoscopy may be more reliable if the atelectasis is due to a foreign body or mucus plug
-physical therapy with percussion and postural drainage may be more successful
-IPPB may result in post-op gastri
how IPPB works in the delivery of aerosolized drugs
-increasing the tidal volume and distributing the aerosol distally
-IPPB devices produce optimal airway particles
-a treatment for 10-20 minutes gives time for airway improvement, allowing increasingly more effective drug delivery
why not to use IPPB for delivery of aeroslized drugs
-a simple device may be just as effective and more tolerable if the patient is dyspnic
-IPPB can be wasteful of drugs, resulting in imprecise dosage
how IPPB works in the treatment of pulmonary edema
-IPPB decreases venous return
-positive pressure may push fluid back into the pulmonary capillaries or lymphatics
-increased tidal volume improves oxygenation resulting in better cardiac activity
-a decreased or slowed breathing pattern is m ore efficient
why not to use IPPB to treat pulmonary edema
-diuretics, oxygen, morphine, and cardiac drugs are more effective
-dyspnic patients may not be able to tolerate IPPB
-IPPB is not as effective as PEEP (positve end expiratory pressure) or CPAP (continuous positive airway pressure)
-IPPB may cause hypoten
how IPPB works to decrease work of breathing
-the lungs are inflated passively
-opening of obstructed airways improves gas flow
why not to use IPPB to decrease work of breathing
-if the patient does not relax, work of breathing is not decreased
-if the patient resists therapy, work of breathing is increased
-if cardiovascular side effects occur, work of the heart will be increased
-IPPB can induce coughing which can increase work
how IPPB works in improvement of pulmonary function tests
-the patient has improved blood gases
-mechanical decrease in airway resistance
-therapy utilizes bronchodilators
why not to use IPPB for improvement of pulmonary function tests
-there is no measurable improvement above what can be done with a more simple therapy
-no long-term improvements are produced in chronic, stable obstructive patients
-loosening of secretions may impact distally
evaluation of IPPB therapy
volume oriented treatment, chest auscultation, pulse, blood pressure, peak flow, sputum production, CXR, cough effectiveness, patient cooperation, patient's subjective comments, blood gas trends
evaluation of IPPB therapy: volume oriented treatment - volume delivered should be ______ ml/kg measured with a wright respirometer
10-15
evaluation of IPPB therapy: chest auscultation, we want to see
-decrease in crackles
-decrease in rhonchi
-decrease in wheeze (could be from clearing of secretions or delivery of a bronchodilator)
evaluation of IPPB therapy: pulse
should improve if their oxygenation improves and work of breathing has decreased
evaluation of IPPB therapy: blood pressure
should come down if oxygenation has improved and work of breathing has improved
evaluation of IPPB therapy: peak flow
measurements should increase
evaluation of IPPB therapy: sputum production
should be enhanced by the IPPB from bronchodilator delivery and delivery of deep breaths
evaluation of IPPB therapy: CXR
should show improved aeration and decreased atelectasis
evaluation of IPPB therapy: cough effectiveness
should improve through increased volume and bronchodilation
evaluation of IPPB therapy: blood gas trends
should improve, sometimes they are only intermittent
goals of IS
-to prevent or treat atelectasis
-this is done by having patient inhale a near normal inspiratory capacity
-it is even more beneficial if the patient can hold to inspiratory capacity for several seconds
determining the need for IS vs. IPPB: if the IC is >80% no treatment is needed unless there is clinical evidence of _________
atelectasis (one of the first signs is a slight fever)
determining the need for IS vs. IPPB: if the final IC is at least 33% of the pre-op value or the VC is at least 10 ml/kg, ______ is indicated
incentive spirometry
determining the need for IS vs. IPPB: if the IC is <33% of the pre-op or the VC is <10 ml/kg, ______ is indicated
IPPB
incentive spirometry: the initial goal is set to the initial inspiratory capacity goal at twice the ______
tidal volume
want to increase the incentive spirometry goal in _____ ml increments as the patient can tolerate it
200
incentive spirometry: the final inspiratory capacity goal should be ____ ml/kg of ideal body weight
12
a normal person should have an inspiratory capacity of about _____% of their FVC
75
want to consider increasing the IS goal if the patient...
is easily able to reach their set goal or if the patient's breath sounds are diminished in the bases
might want to consider decreasing the IS goal if the patient...
cannot reach the set goal because it is too large or if the patient is frustrated and discouraged at the inability to reach goal or if excessive surgical site pain prevents the patient from reaching goal
definition of PEP therapy
used with spontaneous breathing patient to create expiratory pressures between 10-20 cmH2O by changing the size of the expiratory hole they are breathing out of
goal of PEP therapy
-to splint the airways open
-reduce air trapping
-prevent or reduce atelectasis
-help mobilize retained secretions
-maximize delivery of aerosolized bronchodilators (will see this one the most)
indications for PEP therapy
-air trapping due to small airways disease
-atelectasis or the risk of atelectasis
hazards of PEP therapy
-pulmonary barotraumas (pneumothorax, sub-q emphysema, mediastinal emphysema)
-increased intracranial pressure
-myocardial ischemia from decreased venous return
-increased work of breathing
-air swallowing that can lead to vomiting
-claustrophobia
-discom
contraindications from PEP therapy
-untreated pneumothorax
-intracranial pressure > 20
-active hemoptysis
-recent trauma or surgery to the skull, face, mouth, or esophagus
-patient having asthma attack
-acute sinusitis or epistaxis
-tympanic membrane rupture
-nausea
the goal of PEP therapy is to maintain a positive expiratory pressure of ____ with an I:E ration of 1:3
20
during the PEP therapy treatment watch for
dyspnea, pain, chest discomfort, and monitor breath sounds, BP, pulse ox, and skin color
PEP therapy in the conscience patient: have them sit upright, rest their elbows on the table, hold the mask or mouth piece, inhale deeper than normal but not to TLC, exhale fast enough to register ____ cmH2O
10-20
for an acute patient PEP should be done...
every hour for 10-20 minutes, 10 breaths at a time, followed by a huff/hawk cough (moderate breath in and then 3 short burst out)
for someone who you are trying to strengthen and build up their muscles and prevent or reverse atelectasis do PEP therapy...
every 6 hours for 10-20 minutes
in _______ ______, inspiration is active and expiration is passive
spontaneous breathing
in _______ ______ inspiration and expiration are passive
IPPB ventilation