RET 2275 Volume Expasion Therapy

7/28/2019 RET 2275 Volume Expasion Therapy

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Volume Expansion Therapy (VET)

RET 2275

Respiratory Care Theory 2


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Volume Expansion Therapy AKA

Lung expansion therapy

Hyperinflation therapy

A variety or respiratory care modalitiesdesigned to prevent or correct atelectasisby augmenting lung volumes

Incentive Spirometry (IS) Intermittent Positive Airway Pressure (IPPB)

Continuous Positive Airway Pressure (CPAP)

Positive Expiratory Pressure (PEP)


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Atelectasis

Definition: alveolar collapse

Types:

Obstructive Caused by mucus plugging of airways

Passive

Cause by constant tidal breathing of small volumes

Common complication in postoperative patients


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The Sigh Mechanism

Definition:the automatic, periodic inhalation of a large

tidal volume to prevent passive atelectasis

Normally, a person sighs about 6-10 times per hour

Passive atelectasis can occur if this mechanism isimpaired or lost


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The Sigh Mechanism

Factors that can impairthe sigh mechanism

General anesthesia

Pain Pain medication

Decreased level of consciousness

Thoracic or upper abdominal surgery

Impaired diaphragmatic movement


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Sustained Maximal Inspiration (SMI)

A slow, deep inhalation form the FRC up to

(ideally) the total lung capacity, followed by a 5

10 second breath hold

Designed to mimic natural sighing

The negativealveolar & pleural pressuresreexpand collapsed alveoli and prevent the

collapse of ventilated alveoli


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Indications

Presence of pulmonary atelectasis

Presence of condition predisposing to

atelectasis Upper abdominal surgery

Thoracic surgery

Surgery in patient with COPD

Presence of a restrictive lung defect associated withquadriplegia and/or dysfunctional diaphragm


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Hazards & Complications of VET

Ineffective in absence of correct technique (may

require repeated instruction & coaching)

Hyperventilation

Exacerbation of bronchospasm


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Hazards & Complications of VET

Hypoxemia (if O2 therapy is interrupted)

Barotrauma (in emphysematous lungs)

Fatigue

Pain in postoperative patients


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Assessment of Need

Evidence of atelectasis based on physical exam & x-

ray findings

Upper abdominal or thoracic surgery

Presence of predisposing conditions

Presence of neuromuscular disease affecting therespiratory muscles


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Findings Consistent with Atelectasis

Diminished breath sounds & fine crackles in affectedarea

Fever

Tachypnea & tachycardia

Dull percussion note

Characteristic opacity on chest x-ray


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Incentive Spirometry Equipment

Device is only a visual aid

Importance is placed on patient performing the correct

maneuver


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Incentive Spirometry (IS)

Equipment

Volume IS


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Equipment

Flow oriented

(flow x time = volume)


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Administering IS

Physician order required

Instruct patient Importance of deep breathing

Demonstration is the most effective way to assist the

patients understanding and cooperation

Position patient

Sitting or semi-Fowlers

Semi-Fowlers Position

(Head elevated 30)


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Volume Expansion Therapy


Administering IS

RT should set initial goal (e.g. certain volume)

Should require some moderate effort Instruct patient to inspire SLOWLY and deeply

Maximizes distribution of ventilation

Ensure that the patient is using diaphragmatic breathing

Instruct patient to sustain maximal inspiratory

volume for 5 10 seconds followed by a normalexhalation


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Administering IS

Give the patient an opportunity to rest

Some patients need 30 seconds to one minute Helps prevent hyperventilation, dizziness, numbness

around the mouth, respiratory alkalosis

IS regimen should aim to ensure a minimum of 5 -

10 SMI maneuvers each hour

Once technique is mastered, minimum supervision isrequired


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Assessment of Outcome

Absence of or improvement in signs of atelectasis

Normal respiratory & heart rates

Afebrile

Absence of abnormal breath sounds


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Assessment of Outcome

Normal chest x-ray

Improved oxygenation (PaO2/SpO2)

Return of normal spirometric values

Improved respiratory muscle performance


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Charting IS

Pre-treatment vital signs

HR, RR, Breath sounds Initial goal

Example: 800 ml x 10 SMI

Patient toleration

Post-treatment vital signs

Patient education

See examples of charting notes on next slide


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Incentive Spirometry (IS) - Charting

Example of Chart Note:

1/31/06, 08:30 IS given to patient sitting in chair. HR = 80 - 72,

RR = 16 - 14, Breath sounds decreased at bases bilaterally, somefine crackles noted at end inspiration. Obtained IS goal of 2.0 L x 7

SMI. Patient has a dry, non-productive cough. Breath sounds

unchanged after treatment. Patient tolerated treatment without

incident.

Example of Pat ient Educat ion Note:Instructed patient regarding the importance taking deep breaths after

surgery. Demonstrated IS technique for patient. Patient verbalized

understanding of therapy and gave a return demonstration with IS.

Sy Big, MDC Student

Respiratory Care


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Important Points Regarding Use of IS

Verify that there is an indication for therapy

Effective patient teaching & coaching is essential

Demonstrate technique for patient

Teach splinted coughing

Place device within patients reach

Provide rest periods as necessary


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CPAP

Definition

The application of a

positive airway pressure

to the spontaneouslybreathing patient

throughout the

respiratory cycle at

pressures of 5 20 cm

H2O


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CPAP

Physiological Principles

CPAP elevates and maintains high alveolar and

airway pressures throughout the full breathing cycle.


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CPAP

Physiologic Principles - Equipment

The patient on CPAP breaths through a pressurized

circuit against a threshold resistor, with pressures

maintained between 5 20 cm H2O


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CPAP

Physiologic Principles - Equipment


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CPAP

Physiologic Principles

CPAP

Recruits collapsed alveoli via an increase in FRC


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CPAP

Physiologic Principles

CPAP

Recruits collapsed alveoli via an increase in FRC

Decreases work of breathing due to increased complianceor abolition of auto-PEEP

Improves distribution of ventilation through collateral

channels (e.g., Kohns pores)

Increases the efficiency of secretion removal


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CPAP

Indications

Postoperative atelectasis

Cardiogenic pulmonary edema

Refractory hypoxemia

PaO2


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CPAP

Contraindications

Hemodynamic instability

Hypoventilation

CPAP does not ensure ventilation

Nausea

Facial trauma

Untreated pneumothorax

Elevated intracranial pressure


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CPAP

Hazards and Complications

Increased work of breathing caused by the apparatus

Hypoventilation and hypercapnia

Patients with ventilatory insufficiency mayhypoventilate during application

Barotrauma

More likely in patients with emphysema and blebs

Gastric distention (CPAP pressures >15 cm H2O) Vomiting and aspiration in patients with an inadequate gag

reflex


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CPAP

Monitoring and Troubleshooting Patients must be able to maintain adequate excretion

of CO2 on their own

System pressure must be monitored Alarms need to indicate system disconnect or mechanical

failure

Masks may cause irritation and pain

Adequate flow to meet patients need

Flow initially set to 2 3 times the patients minuteventilation

Flow is adequate when the system pressure drops no morethan 1 2 cm H2O during inspiration


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CPAP

Patient Interfaces

Nasal Mask


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CPAP

Patient Interfaces

Fitting the Nasal Mask

Dorsum of nasal bridge Around the nasal alae

Mid philtrum

Use foam bridge

Prevents collapse of maskonto nose


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CPAP

Patient Interfaces

Fitting the Nasal Mask

DO NOT over tighten Tissue necrosis


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CPAP Tissue necrosis


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CPAP

Patient Interfaces

Full-Face Mask


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CPAP

Patient Interfaces

Fitting the Full-Face Mask

Dorum of nasal bridge

Surrounds nose/mouth

Rests below lower lip

DO NOT over tighten

Tissue necrosis

Foam bridge Prevents collapse of mask

onto nose


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CPAP

Nasal vs. Full-Face Mask

Nasal Masks More prone to air leaks (especially mouth

breathers) Use chin strap

Full-Face Mask Increase dead space

Risk of aspiration Claustrophobia

Interferes with expectoration of secretions,communication, eating


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CPAP

Patient Interfaces

Total Face Mask


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EZ-PAP

Lung expansion therapy

during inspiration and

PEP therapy during

exhalation

Used for the treatment orprevention of atelectasis

and the mobilization of

secretions

Aerosol drug therapymay be added to a PEP

session to improve the

efficacy of bronchodilator


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EZ-PAP

EZ-PAP


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EZ-PAP


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EZ-PAP with SVN


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IPPB

Definition

The application of inspiratory positive pressureto a spontaneously breathing patient as an

intermittent or short-term therapeutic modality


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IPPB

Definition

The delivery of a slow deep sustainedinspiration by a mechanical device providing

controlled positive pressure breath during

inspiration


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IPPB

Indications (AARC)

The need to improve lung expansion Treatment of atelectasis not responsive to other

therapies, (e.g., IS and CPT)

Inability to clear secretions adequately

Limited ventilation Ineffective cough


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IPPB

Indications (AARC)

Short-term nonivasive ventilatory support forhypercapnic patients

Alternative to intubation and continuous

ventilatory support


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IPPB

Indications (AARC)

The need to deliver aerosol medication When MDI or nebulizer has been unsuccessful

Patients with ventilatory muscle weakness or

fatigue


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IPPB

Contraindications (AARC)

Tension pneumothorax________________________________________

ICP > 15 mm Hg

Hemodynamic instability

Recent facial, oral or skull surgery


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IPPB


Tracheoesophageal fistula Recent esophageal surgery

Active hemoptysis

Nausea

Air swallowing


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IPPB


Active, untreated TB Radiographic evidence of bleb

Singulus (hiccups)


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IPPB

Hazards (AARC)

Increase airway resistance (Raw) Barotrauma, pneumothorax

Nosocomial infection

Hyperventilation (hypocapnia)

Hemoptysis


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IPPB

Hazards (AARC)

Hyperoxia when O2 is the gas source Gastric distention

Secretion impaction (inadequate humidity)

Psychological dependence

Impedance of venous return


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IPPB

Hazards (AARC)

Exacerbation of hypoxemia Hypoventilation

Increased V/Q mismatch

Air trapping, auto peep, overdistended alveoli


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IPPB

Potential Outcomes

Improved IC or VC Increased FEV1 or peak flow

Enhanced cough or secretion clearance

Improved Chest radiograph

Improved breath sounds


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IPPB

Potential Outcomes

Improved oxygenation Favorable patient subjective response


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IPPB

Baseline Assessment

Vital signs Patients appearance and sensorium

Breathing pattern

Breath sounds


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IPPB

Implementation

Infection control

Equipment preparation Pressure check machine/circuit

Patient orientation Why MD ordered therapy

What treatment does

How it feels

Expected results


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IPPB

Implementation

Application Mouthpiece / nose clip (initially)

Mouthseal

Mask

Trach adaptor


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IPPB

Implementation

Machine settings Sensitivity of 1 2 cm H2O

Initial pressure between 10 15 cm H20

Breathing pattern of 6 breaths/min

I:E ration of 1:3 to 1:4

Flow and pressure will need subsequent

adjustment to patients needs and goal


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IPPB

Implementation

When treating atelectasis Therapy should be volume-oriented

Tidal volumes (VT) must be measured

VT goals must be set

VT goal of 10 15 mL/kg of body weight

Pressure can be increased to reach VT goal if

tolerated by patient


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IPPB

Implementation

When treating atelectasis IPPB is only useful in the treatment of atelectasis

if the volumes delivered exceeds those volumes

achieved by the patients spontaneous efforts


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IPPB

Discontinuation and Follow-Up

Treatments typically last 15-20 minutes Repeat patient assessment

Identify untoward effects

Evaluate progress

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RET 2275 Volume Expasion Therapy