Management of volume loss

Question 1

loss of lung volume

Answer 1

atelectasis/collapse- alveoli, segment, lobe, total lung
other- consolidation, thoracic cage restriction, lung tissue restrictive disease will reduce lung volume, pleural effusion, pneumothorax, abdominal distension compress the lungs

Question 2

Loss of lung volume consolidation

Answer 2

aim to prevent worsening by- mobilisation, hydration, positioning, education of breathing technique

Question 3

problems with atelectasis

Answer 3

reduces amount of functioning lung, reduce SA of ventilated lung, reduced surface area for gas exchange= V/Q mismatch/ decreased SaO2, decreased lung compliance and increased airway resistance, increase work of breathing

Question 4

how can you identify atelectasis

Answer 4

CXR, decreased chest expansion= palpation and observation, auscultation changes, pulse oximetry, ABG

Question 5

what is atelectasis caused by

Answer 5

immobility/prolonged bed rest, poor positioning (supine or slumped sitting), pain, shallow breathing pattern, airway occlusion (mucus plug, tumour in airway, foreign object, airway compression, high O2)

Question 6

why do we want to increase lung volume

Answer 6

increase the amount of functioning lung, increase SA= improve V/Q match and O2 sats, increased lung compliance and decrease airway resistance, decrease WOB, decrease risk of sputum retention and infection

Question 7

what is incentive spirometry

Answer 7

used to increase inhalation breath, tell patient to try and keep ball between smiley faces- encourages deep breathing, do 10 per hour and huff at end

Question 8

IPPB aka the bird

Answer 8

intermittent positive pressure applied during inspiration, pushes patient into IRV, greater volume= improved gas exchange and decrease WOB, patient triggers inspiration by taking a breath and then a sustained positive pressure is applied to the patient’s airway to set a pressure level, followed by passive expiration (stops blowing)
set pressure point (larger pressure=larger breath)

Question 9

Indications for IPPB

Answer 9

atelectasis/volume loss when patient is- tired, drowsy, weak, neurologically impaired, not able to fully participate in more active treatments, may also be used to aid secretion clearance

Question 10

contraindications/precautions

Answer 10

undrained pneumothorax, surgical emphysema, bullae, bronchospasm, recent oesophageal or lung surgery, hypoxic drive patients, active TB, nausea, gastric distension without NG tube, flail chest, broncho pleural fistula, proximal airway tumours, haemoptysis, raised intra cranial pressure, CVS instability

Question 11

how to set up ippb

Answer 11

Starting effort dial, inspiratory pressure gauge, controlled expiratory time, inspiratory flow rate dial, port of connecting IPPB circuit, inspiratory pressure dial

Question 12

IPPB- how to use it

Answer 12

assess patient appropriately and give clear instructions, olace 5mls of normal saline into the nebuliser chamber of the circuit, attach the circuit to the IPPB, choose the most appropriate delivery interface

Question 13

recommended starting setting- sensitivity or starting effort, inspiratory pressure

Answer 13

sensitivity or starting effort- set low to allow patient to breath in easily without increase WOB, inspiratory pressure= 8-15 cmH20 dependent on patient presentation, increasing gradually to approx 20-15 cmH20

Question 14

recommended starting setting- inspiratory flow rate

Answer 14

commence at mid-range, increase if patient is very breathless, increasing time so that the patient has a sustained inspiratory period

Question 15

IPPB- progression

Answer 15

reduce sensitivity if patient is finding it difficult to trigger and increase sensitivity if machine is auto triggering, adjust inspiratory pressure for adequate volume observed by chest expansion (desired pressure=at least 20kpa), adjust inspiratory flow rate to match patients rate of breathing and allow good inspiratory breath time and expansion

Question 16

IPPB- instructions to patient

Answer 16

using appropriate interface instruct patient to: inhale slowly and deeply, allowing the machine to fill their lungs with air and pause briefly at end of inhalation then exhale
ensure good lip seal or use nose clip for mouthpiece, ensure no puffing, 6-8 breath

Question 17

NIPPY clearway and cough assist

Answer 17

can be used to give deeper breaths by increasing inspiratory pressure, is a mechanical insufflation (positive inspiratory pressure)- exsufflation (negative pressure applied to clear secretions) (MI-E), can be used with different interface (mouthpiece, face a mask or tracheostomy connector), can set the pressure and the time taken in both I and E

Question 18

NIPPY clearway- uses

Answer 18

due to its many modes the machine can be used to increase volumes, remove secretions and as non invasive ventilation, same contraindications/precautions as any other positive pressure devices q

Question 19

continuous positive airway pressure (CPAP)

Answer 19

As the name suggests it is positive pressure applied throughout the whole respiratory cycle (i.e. inspiration and expiration), used in spontaneously breathing patients, keeps the airway pressure higher than atmospheric throughout the whole respiratory cycle, it delivers a constant flow of gas which exceeds the patients demand, this will increase FRC above CV thus recruiting collapsed alveoli and maintaining higher lung volume

Question 20

neurophysiological facilitation

Answer 20

use of proprioceptive stimuli producing a reflex which increases the depth of inspiration, intercostal stretch, rib springing
perinorsi- pressure on top of lip, rib springing- end of breath squeeze ribs down and in- causes deeper breath