Chapter 43

Question 1

What is Lung Expansion Therapy?

Answer 1

*used to keep the alveoli open
*often used with other therapies to keep the bronchi free of secretions and fully bronchodilated
*also called bronchopulmonary toilet or bronchial hygiene therapy

Question 2

what are some Natural Lung Expansion Mechanisms?

Answer 2

1.Yawn or sigh
2.Coughing
3. Mucociliary escalator

Question 3

Yawn or sigh

Answer 3

a large, deep breath which will pop open the alveoli to prevent -
Passive Atelectasis

Question 4

Passive Atelectasis

Answer 4

alveoli have closed down because of a lack of deep breaths, you breathe with the same size tidal volume every breath

Question 5

Coughing

Answer 5

keeps airway clear by moving secretions along (100ml mucus a day) helps prevent -
Reabsorption atelectasis

Question 6

Reabsorption atelectasis

Answer 6

secretions plug the airway off; no fresh gas gets to the alveoli so the gas in the alveolus is also absorbed

Question 7

Mucociliary escalator

Answer 7

the cilia move mucous of normal amounts and thickness.

Question 8

How does atelectasis happen?

Answer 8

*when FRC is decreased, we develop a decreased lung compliance (lung is stiffer, not as stretchable)
*much easier to take frequent shallow breathes than to work at stretching a stiff lung
*Vicious Cycle
*Shallow breathing and not coughing leads to retained secretion and infection can result

Question 9

Vicious Cycle

Answer 9

more shallow breaths lead to more atelectasis thus leading to a further decrease in FRC

Question 10

Functional Residual Capacity (FRC)

Answer 10

the normal amount of gas left in your lungs at the end of a normal exhalation

Question 11

Factors Associated with Atelectasis

Answer 11

*Obesity – post op comp
*Neuromuscular disorders
*Heavy sedation
*Surgery near diaphragm
*Bed rest
*Poor cough
*History of lung disease
*Restrictive chest-wall abnormalities – scoliosis

Question 12

Clinical Signs of Atelectasis

Answer 12

*History of recent major surgery
*Tachypnea
*Fine, late-inspiratory crackles
*Bronchial or diminished breath sounds
*Tachycardia
*Increased density and signs of volume loss on chest radiograph

Question 13

Types of Lung Expansion Therapy

Answer 13

PEP (Positive Expiratory Pressure)
IPPB (Intermittent Positive Pressure Breathing)
IPV (Interpulmonary Percussive Ventilation)
IS (Incentive Spirometry)
**These are the most common therapies used to maximize lung expansion and prevent atelectasis

Question 14

PEP (Positive Expiratory Pressure)

Answer 14

-Traditional, Vibratory/Oscillatory – purse lip breathing with a devise or extra stuff (COPD – air trapping bc airways collapse)

Question 15

IPPB (Intermittent Positive Pressure Breathing)

Answer 15

just lung expansion

Question 16

IPV (Interpulmonary Percussive Ventilation)

Answer 16

breathe percussive breaths

Question 17

IS (Incentive Spirometry)

Answer 17

just lung expansion - Inhale Slowly
*mimics the natural sigh or yawn by encouraging slow, deep breaths
* the patient must do the work

Question 18

Indications for IS

Answer 18

-presence of or risk of developing atelectasis (thoracic or abdominal surgery)
o-patients with Neuromuscular disease (ALS)
-restrictive lung disease (quadriplegia)

Question 19

Guidelines for IS

Answer 19

**IC- inspiratory capacity (Vt +IR)
-IC> 80% of preoperative value—treatment not indicated
-IC < 2.5 L—IS is indicated
-Treatment goal for IS should be an initial IC of 2X the Vt.
-Increase the goal in 200 ml increments as tolerated
-FVC < 70% of predicted or VC < 10 ml/kg—IPPB is indicated
(forced vital capacity – everything but rv)

Question 20

Outcomes for IS

Answer 20

-increased lung volumes
-decreased RR and HR
-improved breath sounds
-decreased WOB
-increased PaO2
-improved chest x-rays

Question 21

Hazards and Complications for IS

Answer 21

-Hyperventilation and respiratory alkalosis – dizzy and tingling fingers
-Discomfort secondary to inadequate pain control
-Pulmonary barotrauma – pneumothorax
-Exacerbation of bronchospasm
-Fatigue

Question 22

Contraindications for IS

Answer 22

-confused, uncooperative patients
-unable to take deep breathes (Vital capacity < 10ml/kg)

Question 23

Advantages for IS

Answer 23

-easy, inexpensive therapy with very few side effects
-patient gets visual feedback on their progress
-can be done without the therapist

Question 24

Volume Displacement IS

Answer 24

-as the patient inhales through a mouthpiece, a volume is displaced
-at maximal volume, the patient should hold the breath for 3-5 seconds
before exhaling
-should do 5-10 breaths every hour while awake – IS q1
-some devices have a flow indicator to encourage the patient to take a slow, deep breath

Question 25

Flow Dependent IS

Answer 25

-contains a manifold of 3 tubes each containing a lightweight ball
-negative pressure in the tubes causes the balls to rise
-the number of balls that rise and the level to which they rise measures the flow achieved
-smaller devices, but more difficult to perform

Question 26

other important notes for IS

Answer 26

*the breath hold allows the pressure in the lungs to equilibrate
*as the patient achieves more volume for the same effort, they are getting better

Question 27

Intermittent Positive Pressure Breathing

Answer 27

foundation of mechanical ventilation
*delivery of positive inspiratory pressure to a spontaneously breathing patient (the opposite of how we normally breathe)
*beneficial to patients for whom IS, CPT, and deep breathing have not been effective; the machine does the work for the patient

Question 28

Indications for IPPB

Answer 28

-lung expansion therapy, especially for those unable to do IS
-aerosolized medication

Question 29

IPPB Operation

Answer 29

*machine requires a 45-55 psi pressure source
*inspiration begins when the patient creates a negative pressure and ends when a preset pressure is reached
*the amount of negative pressure the patient must generate to start the breath (trigger) depends on the sensitivity set on the machine (set by the therapist)
*the pressure that must be reached to end inspiration (limit) and allow exhalation to occur (cycle) is also set on the machine (set by the therapist)
*the goal of IPPB is to deliver a volume, not a pressure to the patient
*the amount of volume the patient gets for a pressure depends on the condition of the lungs; less compliant lungs get less volume for the same pressure
*treatment should last 15-20 minutes

Question 30

Contradictions of IPPB

Answer 30

*ICP greater than 15 mm Hg
*Hemodynamic instability
*Active hemoptysis
*Tracheoesophageal fistula
*Recent esophageal surgery
*Active, untreated tuberculosis
*Radiographic evidence of blebs
*Recent facial, oral, or skull surgery
*Singultus (hiccups)

Question 31

Side Effects of IPPB

Answer 31

-barotrauma (pushing air into a weak lung can pop it) (a stiff lung) Volutrauma (over compliant lung)
-hyperventilation (gives big breaths, removes more CO2)
-Cardiovascular effects—IPPB can decrease Venous Return to the heart, this will cause a drop-in blood pressure
*E time should be twice as long as I time, this allows blood to return to the heart between breaths

Question 32

Bird IPPB Machine

Answer 32

*pneumatically powered
*time, pressure (preferred), or manually triggered
*time or pressure cycled
machine must be cleaned, line is disposable

Question 33

Gas Flows in Bird IPPB Machine

Answer 33

-gas leaving the compartment travels to a Venturi jet, a nebulizer power line, and the exhalation valve

-the Venturi jet entrains air and the gas moves to the patient

-as pressure builds, the Venturi jet closes; the gas flow to the exhalation valve stops, so the valve opens to allow the patient to exhale

Question 34

Air Mix Control in Bird IPPB Machine

Answer 34

-On: gas is directed to the Venturi jet.
*Delivered gas comes from the Venturi jet, the air it entrains, and the nebulizer.
*has a decelerating flow pattern, good for obstructed patients (COPD, asthma)

-Off: gas never goes to the Venturi jet, no air in entrained, FiO2=100%
*has a constant, square wave flow

Question 35

Flow Control on Bird IPPB Machine

Answer 35

-increasing the flow will decrease the time for the breath
-high flow is more turbulent, pressure builds faster, so breath is shorter – flow control
-obstructed patients will not get a good volume if the flow is too fast