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LUNG EXPANSION IS, PAP , PEP, IPPB, IPV, PEEP/CPAP and BIPAP. Atelectasis. Causes Surgery Upper abdominal surgery risk greater than lower abdominal Thoracic surgery. Atelectasis. Causes Obesity Neuromuscular disorders Sedation. Atelectasis. Causes Spinal cord injuries

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  2. Atelectasis • Causes Surgery • Upper abdominal surgery risk greater than lower abdominal • Thoracic surgery

  3. Atelectasis • Causes • Obesity • Neuromuscular disorders • Sedation

  4. Atelectasis • Causes • Spinal cord injuries • Non-ambulation/bed rest • Ineffective cough

  5. Types of Atelectasis • Reabsorption atelectasis • Caused by the blockage of airways by mucus plugs; associated with lobar or segmental atelectasis

  6. Types of Atelectasis • Passive atelectasis • Caused by persistent use of small tidal volumes, use of sedatives and bed rest, when deep breathing is painful, and weakened diaphragm

  7. Clinical Signs of Atelectasis • Increase in respiratory rate • Fine, late inspiratory crackles during auscultation • Diminished breath sounds

  8. Clinical Signs of Atelectasis • Tachycardia, if there is significant hypoxemia associated with the atelectasis • Fever

  9. Clinical Signs of Atelectasis • X-Ray • Increased opacity • Air bronchograms

  10. Clinical Signs of Atelectasis • X-Ray • Elevation of diaphragm • Shift of trachea, heart, or mediastinum toward the affected side

  11. Lung Expansion Therapy • Increases transpulmonary pressure (PL) PL = Palv – Ppl • Decrease in Ppl by a sustained inspiratory phase; more physiological • Increase in Palv by use of positive pressure

  12. Lung Expansion Therapy • Goal is to choose most effective means in most efficient manner

  13. Methods of Administration • Incentive spirometry • Also known as sustained maximal inspiration (SMI) • Slow, deep inspiration from FRC to TLC followed by a 5 to 10 second hold

  14. Methods of Administration • Incentive spirometry • Functionally equivalent to performing inspiratory capacity with breath hold

  15. Incentive Spirometry • Indications • Presence of conditions predisposing to development of atelectasis • Presence of atelectasis

  16. Incentive Spirometry • Indications • Presence of restrictive lung defect associated with quadriplegia and/or dysfunctional diaphragm

  17. Incentive Spirometry • Contraindications • Patient unable to understand instructions well enough to ensure effective use of the spirometer

  18. Incentive Spirometry • Contraindications • Patient unwilling to cooperate or cannot demonstrate ability to use the device • Patient unable to deep breathe effectively (VC < 10 ml/kg)

  19. Incentive Spirometry • Hazards and complications • Hyperventilation leading to respiratory alkalosis • Ineffectiveness unless supervised or performed as ordered

  20. Incentive Spirometry • Hazards and complications • Exacerbation of bronchospasm • Barotrauma • Fatigue

  21. Incentive Spirometry • Hazards and complications • Discomfort secondary to inadequate pain control • Hypoxemia secondary to removal of oxygen to perform the therapy

  22. Monitoring IS Treatment • Observation of patient performance and use • Frequency of sessions • Number of breaths per session • Volume/flows achieved

  23. Monitoring IS Treatment • Observation of patient performance and use • Breath hold sustained • Vital signs, including breath sounds • Motivation of patient

  24. Monitoring IS Treatment • Observation of patient performance and use • Device available to patient • Reassessment of daily goals • Additional instruction, as needed

  25. Monitoring IS Treatment • Direct supervision of each procedure not required once patient has mastered technique

  26. Assessment of Outcome • Absence or improvement of atelectasis • Decrease/normalization of respiratory rate • Resolution of fever • Absence of crackles or increase in breath sounds

  27. Assessment of Outcome • Normal X-Ray • Improved PaO2 • Increase in VC and peak expiratory flows

  28. Incentive Spirometry Volumetric IS Flow Oriented IS

  29. PEP and PAP

  30. PAP • Positive airway pressure (PAP) adjuncts are used to mobilize secretions and treat atelectasis and include • continuous positive airway pressure (CPAP) • positive expiratory pressure (PEP) • expiratory positive airway pressure (EPAP). • Cough or other airway clearance techniques are essential components of PAP therapy when the therapy is intended to mobilize secretions

  31. Terminology • PAP: positive airway pressure. This is a universal term, applied to any positive pressure application to the lung. No single device is called PAP, instead it encompasses all devices that deliver positive pressure • PEP: Positive expiratory pressure. Typically given as a expiratory retard, or expiratory impendence/resistor. Devices include the flutter, EZPAP, therapep or simply performing pursed lip breathing. PEP also includes PEEP, however, when we say “PEP” we are referring to a device such as those listed above.

  32. Terminology • PEEP: Again, PEEP is PEP; however, we refer to PEEP as a setting on mechanical ventilation. Typically it is referring to extrinsic PEEP, or PEEP that is applied to the airway through mechanical ventilation. • EPAP: EPAP, PEP and PEEP are all expiratory pressures a patient must exhale against. This term is however used while a patient is on BiPAP ventilation/ also known as Bilevel ventilation or non-invasive positive pressure ventilation.

  33. Devices

  34. MetaNeb/Cough Assist

  35. PAP: CPAP • The patient breathes from a pressurized circuit against a threshold resistor (water-column, weighted, or spring loaded) that maintains consistent preset airway pressures from 5 to 20 cm H2O during both inspiration and expiration • (By strict definition, CPAP is any level of above-atmospheric pressure.) • CPAP requires a gas flow to the airway during inspiration that is sufficient to maintain the desired positive airway pressure.

  36. PAP: CPAP • Types of threshold resistors: all of these valves operate on the principle that the level of PAP generated within the circuit depends on the amount of resistance that must be overcome to allow gas to exit the exhalation valve. • They provide predictable, quantifiable, and constant force during expiration that is independent of the flow achieved by the patient during exhalation

  37. PAP: CPAP • Underwater seal resistor: • expiratory port of the circuit is submerged under a column of water, the level of CPAP is determined by the height of the column • Weighted-ball resistor: • consists of a steel ball placed over a calibrated orifice, which is attached directly above the expiratory port of the circuit

  38. PAP: CPAP • Spring-loaded: • rely on a spring to hold a disc or diaphragm down over the expiratory port of the circuit. • Magnetic valve resistors • contain a bar magnet that attracts a ferromagnetic disc seated on the expiratory port of the circuit the amount of pressure required to separate the disc from the magnets is determined be the distance between them.

  39. PAP: PEP • The patient exhales against a fixed-orifice resistor, generating pressures during expiration that usually range from 10 to 20 cm H2O • PEP does not require a pressurized external gas source. • The amount of PEP varies with the size of the orifice and the level of expiratory flow produced by the patient. The smaller the orifice the greater the pressure.

  40. PAP: PEP • Thus the patient must be encourage to generated a flow high enough to maintain expiratory pressure at 10-20 mm H2O • Ideal I:E of 1:3 or 1:4 • The patient should perform 10-20 breaths through the device and then perform 2-3 huff breath coughs • This should be repeated 5-10 times during a 15-20 minute session

  41. PAP: EPAP • The patient exhales against a threshold resistor, generating preset pressures of 10 to 20 cm H2O (similar to CPAP expiration) • EPAP does not require a pressurized external gas source. • EPAP utilizing threshold resistors does not produce the same mechanical or physiologic effects that PEP does when a fixed orifice resistor is used. • Further study is necessary to determine how these differences affect clinical outcome.

  42. Intermittent Positive Pressure Breathing

  43. IPPB • Intermittent Positive Pressure Breathing (IPPB) is a short-term breathing treatment where increased breathing pressures are delivered via ventilator to help treat atelectasis, clear secretions or deliver aerosolized medications • IPPB can include pressure- and time-limited, as well as pressure, time, and flow-cycled ventilation. • IPPB may be delivered to artificial airways and non-intubated patients.

  44. IPPB • INDICATIONS:The need to improve lung expansionThe presence of clinically significant pulmonary atelectasis when other forms of therapy have been unsuccessful (incentive spirometry, chest physiotherapy, deep breathing exercises, positive airway pressure) or the patient cannot cooperate

  45. IPPB • Inability to clear secretions adequately because of pathology that severely limits the ability to ventilate or cough effectively and failure to respond to other modes of treatment • The need for short-term ventilatory support for patients who are hypoventilating as an alternative to tracheal intubation and continuous mechanical ventilation

  46. IPPB • The need to deliver aerosol medication. • IPPB may be used to deliver aerosol medications to patients with fatigue as a result of ventilatory muscle weakness (eg, failure to wean from mechanical ventilation, neuromuscular disease, kyphoscoliosis, spinal injury) or chronic conditions in which intermittent ventilatory support is indicated (eg, ventilatory support for home care patients and the more recent use of nasal IPPV for respiratory insufficiency)

  47. IPPB • Assessment of need: • Presence of significant atelectasis • Reduced pulmonary function, reduced VC, VT • Neuromuscular disorders • Prevention of atelectasis Assessment of Outcome: • Minimum VT of at least 1/3 of predicted IC • Increase in FEV1 • More effective cough, CXR improved, BS improved

  48. IPPB • CONTRAINDICATIONS:There are several clinical situations in which IPPB should not be used. With the exception of untreated tension pneumothorax, most of these contraindications are relative: • Increased ICP >15 mmHg • Hemodynamically unstable • Recent Facial, oral or skull surgery • Tracheoesphogeal fistula

  49. IPPB • Recent Espohageal surgery • Active hemoptysis • Nausea • Air swallowing • Active TB • Blebs • Singulation (hiccups)

  50. IPPB • Hazards/complications • Increased RAW and WOB • Barotrauma/pneumothorax • Nosocomial infection • Hypocarbia • Hemoptysis • Hyperoxia when O2 used as gas source • Gastric distension • Impaction of secretions

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