Pulmonary complications are common serious problems seen in patients who have:
undergone thoracic or upper abdominal surgery
Pulmonary complications include:
atelectasis, pneumonia, and acute respiratory failure.
Lung expansion therapy is used to
prevent or correct respiratory complications in the postoperative period.
What are the 2 types of Atelectasis?
Resorption Atelectasis & Passive Atelectasis
Resorption Atelectasis:
occurs when mucus plugs block ventilation to selected regions of the lung; gas distal to the obstruction is absorbed by the passing blood. Mucus plug causing atelectasis
Passive Atelectasis
is caused by persistent breathing with small tidal volumes (small volume) Vt. persistent small tidal volumes causing atelectasis.
What are the factors associated with causing Atelectasis?
� Obesity
� Neuromuscular disorders
� Heavy sedation
� Surgery near diaphragm
� Bed rest
� Poor cough
� History of lung disease such as COPD
What are the clinical signs of Atelectasis?
� History of recent major surgery
� Tachypnea
� Fine, late-inspiratory crackles
� Bronchial or diminished breath sounds
� Tachycardia
� Increased density and signs of volume loss on the chest radiograph (CXR)
� Can happen in segments or in lobes
? Segment
What are the 3 types of lung expansion therapy?
Incentive Spirometry, Intermittent Positive Pressure Breathing, and Positive Airway Pressure Therapy.
Incentive Spirometry (IS)
� Has been the mainstay of lung expansion therapy for many years.
� I.S. devices provide visual cues to the patient when a desired inspiratory volume of flow is reached.
� Has proved to be effective in high-risk patients.
� Mimics natural sighing by encou
Equipment for Incentive Spirometry
� Typically simple, portable, and inexpensive.
� I.S. device are either flow oriented or volume oriented.
� Flow-oriented devices are more popular because they are smaller.
Administration of IS
� The need for I.S. is determined by careful patient assessment (high-risk patient).
� Basic maneuver is a sustained maximal inspiration (SMI)- slow deep inhalation from FRC followed by a 5 to 10 second breath hold.
� Effective patient teaching
? Demonstr
Patient should sustain his/her maximal inspiratory effort for
5 to 10 sec
How many maneuvers an hour should you aim for?
5-10 maneuvers
Indications for IS
� Presence of pulmonary atelectasis
� Presence of conditions predisposing to atelectasis:
? Upper abdominal surgery
? Thoracic surgery
? Surgery in patients with COPD
� Presence of restrictive lung defect associated with quadriplegia and/or dysfunctional
Contraindications for IS
� Unconscious patients or those unable to cooperate.
� Patients who cannot properly use I.S. device after instruction.
� Patients unable to generate adequate inspiration
? VC< 10ml/kg
? IC< 33% of predicted normal
� The presence of an open tracheal stoma
What are the values for patient to generate adequate inspiration (VC and IC) for IS?
VC>10ml/kg
IC<33%
What are the Hazards and Complications for IS?
� Ineffective unless performed correctly
� Hyperventilation and respiratory alkalosis (#1)
� Discomfort secondary to inadequate pain control
� Pulmonary barotrauma (injury caused by a change in air pressure, typically affecting the ear or the lung)
� Exac
What are the potential outcomes of Incentive Spirometry?
� Absence of or improvement in signs of atelectasis
� Decreased respiratory rate
� Normal Pulse rate
� Resolution of abnormal breath sounds
� Normal or improved chest radiograph
� Improved PaO2 and decreased PaCO2
� Increased VC and peak expiratory flows
Intermittent Positive Pressure Breathing (IPPB)
� Uses positive airway pressure to expand the lung.
� Treatments last 15 to 20 minutes.
� Exhalation is passive.
� Patients who breathe on their own (could be obtunded)
Treatment for the IPPB lasts:
15 to 20 minutes.
Indications for IPPB
� The need to improve lung expansion
? The presence of clinically important pulmonary atelectasis when other forms of therapy (e.g. IS) have been unsuccessful or the patient cannot cooperate.
? Inability to clear secretions adequately because of pathology
Contraindications for IPPB
� Tension pneumothorax (A)
� ICP > 15 mm hg
� Hemodynamic (" blood, change") instability
� Active Hemoptysis (coughing up of blood)
� Tracheoesophageal fistula
� Recent esophageal surgery
� Active, untreated tuberculosis (an infectious bacterial disease c
What is the absolute contraindication of IPPB?
� Tension pneumothorax
Hazards and Complications of IPPB
� Increased airway resistance
� Pulmonary barotrauma, Pneumothorax
� Nosocomial infection
� Respiratory alkalosis
� Hyperoxia (with O2 as source gas)
� Impaired venous return
� Gastric distention
� Air trapping, auto-PEEP, overdistension (cause something
Potential Outcomes of IPPB Therapy
� Improved VC
� Increased FEV1 or peak flow
� Enhanced cough and secretion clearance
� Improved chest radiograph
� Improved breath sounds
� Improved oxygenation
� Favorable patient subjective response
Administration of IPPB includes:
� Preliminary planning
� Implementation
� Equipment preparation
� The patients orientation
� Patient positioning
� Adjusting parameters
� Bird Mark 7- Classification
� Pressure Cycled
� Initial settings
� Flowrate
� Expiratory Timer
� Air Mix Control
� Tr
IPPB Preliminary planning
? Therapeutic outcomes set
? Evaluate alternatives
? Baseline assessment of the patient
IPPB Equipment preparation
it's the RTs responsibility to ensure all components are in proper working order before using on patients.
IPPB patient's orientation
explain the purpose of the treatment
IPPB Patient positioning
Semi-Fowlers or Supine (lying face upward
Adjusting parameters
? Flow
? Pressure
IPPB Bird Mark 7- Classification
? Positive pressure ventilator
� Pushes air into the lungs
? Pneumatically powered
� Runs on a gas source doesn't require electricity
? Pneumatically driven
? Single circuit
� The same gas supply goes to the patient that powers the machine
IPPB Pressure Cycled
? Cycling is what ends inspiration
? When pressure is reached, machine ends inspiration
IPPB Initial settings for Sensitivity
? Sensitivity- how easy it is for the machine to sense the patient is taking a breath.
� Set -1 to -2 cm H2O below ambient
� Located on the left side of the machine
IPPB initial settings for Pressure
? Pressure
� Inflates the lungs
� Located on the right side of the ventilator
� Initially set to 10- 15 cm H2O
� An increase in pressure, increase volume
IPPB Flowrate
? Located on the front of the machine
? Adjustment regulates gas flow
? Initially set at 15 LPM (low to moderate)
? Can be set up to 80 LPM
? The higher the flow, the faster the breath is delivered resulting in a short I time and a long E time.
IPPB Expiratory Timer
? Only used when using the machine as a ventilator
? We don't set if using the machine for IPPB
IPPB Air Mix Control
? If the knob is pulled out (in the "on" position) FiO2 varies between 65% and 95% (depends on the peak pressures and Vt)
? If the knob is pushed in the FiO2 will be 100%
IPPB Troubleshooting
? Large pressure settings- increase sensitivity until -1 to -2 cm H2O is needed to trigger the device.
? System pressure drops after beginning inspiration- flow is too low.
? Device cycles off prematurely- flow is too high or there is and airflow obstruct
If the knob is pulled out (in the "on" position) FiO2 varies:
between 65% and 95%
If the knob is pushed in the FiO2 will be:
100%
What is the flowrate of IPPB initially set at?
15 LPM
What is the highest that the IPPB flowrate can be set at?
80 LPM
Indications for CPAP
�Treatment of atelectasis
�Treatment of cardiogenic (originates in the heart) pulmonary edema (in the interstitial space)
Contraindications for CPAP
�Hemodynamic instability
�Patient with hypoventilation
Hazards and Complications of CPAP:
�Barotrauma
�Hypoventilation
�Gas distention
�Vomiting and aspiration
What is the most common problem with PAP therapies?
System leaks
Monitoring and Troubleshooting with CPAP therapies
�The most common problem with PAP therapies is system leaks.
�Patient must be monitored for hypoventilation and evaluated PCO2
�Inspiratory flow must be adequate
Selecting an Approach
�Chose the modality that is the safest, simplest, and most effective.
The respiratory therapist should evaluate the following before choosing specific modality:
Level of patient cooperation
Amount of pulmonary secretions
Patient's spontaneous vital capacity.