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Volume Expansion Therapy (VET)
RET 2275
Respiratory Care Theory 2
Volume Expansion Therapy (VET)
Volume Expansion Therapy AKA
Lung expansion therapy Hyperinflation therapy
A variety or respiratory care modalities designed to prevent or correct atelectasis by augmenting lung volumes
Incentive Spirometry (IS) Intermittent Positive Airway Pressure (IPPB) Continuous Positive Airway Pressure (CPAP) Positive Expiratory Pressure (PEP)
Volume Expansion Therapy (VET)
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
Volume Expansion Therapy (VET)
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 is impaired or lost
Volume Expansion Therapy (VET)
The Sigh Mechanism Factors that can impair the sigh mechanism
General anesthesia Pain Pain medication Decreased level of consciousness Thoracic or upper abdominal surgery Impaired diaphragmatic movement
Volume Expansion Therapy (VET)
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 negative alveolar & pleural pressures reexpand collapsed alveoli and prevent the collapse of ventilated alveoli
Volume Expansion Therapy (VET)
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 with quadriplegia and/or dysfunctional diaphragm
Volume Expansion Therapy (VET)
Contraindications for VET
Inability of patient to be instructed to perform SMI maneuver
Lack of patient cooperation
Inability of patient to deep breathe (i.e. VC <10 ml/kg)
Volume Expansion Therapy (VET)
Hazards & Complications of VET
Ineffective in absence of correct technique (may require repeated instruction & coaching)
Hyperventilation
Exacerbation of bronchospasm
Volume Expansion Therapy (VET)
Hazards & Complications of VET
Hypoxemia (if O2 therapy is interrupted)
Barotrauma (in emphysematous lungs)
Fatigue
Pain in postoperative patients
Volume Expansion Therapy (VET)
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 the respiratory muscles
Volume Expansion Therapy (VET)
Findings Consistent with Atelectasis
Diminished breath sounds & fine crackles in affected area
Fever
Tachypnea & tachycardia
Dull percussion note
Characteristic opacity on chest x-ray
Volume Expansion Therapy (VET)
Incentive Spirometry Equipment
Device is only a visual aid
Importance is placed on patient performing the correct maneuver
Volume Expansion Therapy (VET)
Incentive Spirometry (IS) Equipment
Volume IS
Volume Expansion Therapy (VET)
Incentive Spirometry (IS) Equipment
Flow oriented (flow x time = volume)
Volume Expansion Therapy (VET)
Incentive Spirometry (IS) Administering IS
Physician order required Instruct patient
Importance of deep breathing Demonstration is the most effective way to assist the
patient’s understanding and cooperation Position patient
Sitting or semi-Fowler’s
Semi-Fowler’s Position (Head elevated 30)
Volume Expansion Therapy
Incentive Spirometry (IS) 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 normal exhalation
Volume Expansion Therapy
Incentive Spirometry (IS) 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 is
required
Volume Expansion Therapy (VET)
Assessment of Outcome
Absence of or improvement in signs of atelectasis
Normal respiratory & heart rates
Afebrile
Absence of abnormal breath sounds
Volume Expansion Therapy (VET)
Assessment of Outcome
Normal chest x-ray
Improved oxygenation (PaO2/SpO2)
Return of normal spirometric values
Improved respiratory muscle performance
Volume Expansion Therapy
Incentive Spirometry (IS) 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
Volume Expansion Therapy (VET)
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, some fine 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 Patient Education 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 StudentRespiratory Care
Volume Expansion Therapy (VET)
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 patient’s reach
Provide rest periods as necessary
CPAP
Definition The application of a
positive airway pressure to the spontaneously breathing patient throughout the respiratory cycle at pressures of 5 – 20 cm H2O
CPAP
Physiological Principles CPAP elevates and maintains high alveolar and
airway pressures throughout the full breathing cycle.
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
CPAP
Physiologic Principles - Equipment
CPAP
Physiologic Principles CPAP
Recruits collapsed alveoli via an increase in FRC
CPAP
Physiologic Principles CPAP
Recruits collapsed alveoli via an increase in FRC Decreases work of breathing due to increased compliance
or abolition of auto-PEEP Improves distribution of ventilation through collateral
channels (e.g., Kohn’s pores) Increases the efficiency of secretion removal
CPAP
Indications Postoperative atelectasis
Cardiogenic pulmonary edema Refractory hypoxemia
PaO2 <60 mm Hg, SaO2 <90% on an FiO2 >0.40 – 0.50 in the presence of adequate ventilatory status (PaCO2 <45 mm Hg, pH 7.35 – 7.45)
Obstructive sleep apnea
CPAP
Contraindications Hemodynamic instability Hypoventilation
CPAP does not ensure ventilation Nausea Facial trauma Untreated pneumothorax Elevated intracranial pressure
CPAP
Hazards and Complications Increased work of breathing caused by the apparatus
Hypoventilation and hypercapnia Patients with ventilatory insufficiency may
hypoventilate 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
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 patient’s need
Flow initially set to 2 – 3 times the patients minute ventilation
Flow is adequate when the system pressure drops no more than 1 – 2 cm H2O during inspiration
CPAP
Patient Interfaces
Nasal Mask
CPAP
Patient Interfaces
Fitting the Nasal Mask Dorsum of nasal bridge Around the nasal alae Mid philtrum Use foam bridge
Prevents collapse of mask
onto nose
CPAP
Patient Interfaces
Fitting the Nasal Mask DO NOT over tighten
Tissue necrosis
CPAP – Tissue necrosis
CPAP
Patient Interfaces
Full-Face Mask
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
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
CPAP
Patient Interfaces
Total Face Mask
EZ-PAP
Lung expansion therapy during inspiration and PEP therapy during exhalation
Used for the treatment or prevention of atelectasis and the mobilization of secretions
Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator
EZ-PAP
EZ-PAP
EZ-PAP
EZ-PAP with SVN
IPPB
Definition
The application of inspiratory positive pressure to a spontaneously breathing patient as an intermittent or short-term therapeutic modality
IPPB
Definition
The delivery of a slow deep sustained inspiration by a mechanical device providing controlled positive pressure breath during inspiration
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
IPPB
Indications (AARC)
Short-term nonivasive ventilatory support for hypercapnic patients Alternative to intubation and continuous
ventilatory support
IPPB
Indications (AARC)
The need to deliver aerosol medication When MDI or nebulizer has been unsuccessful Patients with ventilatory muscle weakness or
fatigue
IPPB
Contraindications (AARC)
Tension pneumothorax
________________________________________
ICP > 15 mm Hg Hemodynamic instability Recent facial, oral or skull surgery
IPPB
Contraindications (AARC)
Tracheoesophageal fistula Recent esophageal surgery Active hemoptysis Nausea Air swallowing
IPPB
Contraindications (AARC)
Active, untreated TB Radiographic evidence of bleb Singulus (hiccups)
IPPB
Hazards (AARC)
Increase airway resistance (Raw) Barotrauma, pneumothorax Nosocomial infection Hyperventilation (hypocapnia) Hemoptysis
IPPB
Hazards (AARC)
Hyperoxia when O2 is the gas source Gastric distention Secretion impaction (inadequate humidity) Psychological dependence Impedance of venous return
IPPB
Hazards (AARC)
Exacerbation of hypoxemia Hypoventilation Increased V/Q mismatch Air trapping, auto peep, overdistended alveoli
IPPB
Potential Outcomes
Improved IC or VC Increased FEV1 or peak flow Enhanced cough or secretion clearance Improved Chest radiograph Improved breath sounds
IPPB
Potential Outcomes
Improved oxygenation Favorable patient subjective response
IPPB
Baseline Assessment
Vital signs Patient’s appearance and sensorium Breathing pattern Breath sounds
IPPB
Implementation
Infection control Equipment preparation
Pressure check machine/circuit Patient orientation
Why MD ordered therapy What treatment does How it feels Expected results
IPPB
Implementation
Application Mouthpiece / nose clip (initially) Mouthseal Mask Trach adaptor
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 patient’s needs and goal
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
IPPB
Implementation
When treating atelectasis IPPB is only useful in the treatment of atelectasis
if the volumes delivered exceeds those volumes achieved by the patient’s spontaneous efforts
IPPB
Discontinuation and Follow-Up
Treatments typically last 15-20 minutes Repeat patient assessment Identify untoward effects Evaluate progress Document