RCP 120 Unit 4 Flashcards
-Lung Expansion Therapy
-Incentive spirometry (I.S.)
-Continuous Positive Airway Pressure (CPAP) -Intermittent Positive Pressure Breathing (IPPN) -EZPAP -Deep breathing and cough -Frequent Positioning -Early ambulation -Best choice is what will accomplish what is needed at least cost!!
-Incentive Spirometry
-Designed to mimic natural sighing, performed using devices which provide a visual cue.
-Basaic maneuver-SMI- sustained maximal inspiration -Slow deep inspiration from FRC to total lung capacity, followed by 3-5 second breath hold -Drop in transpleural pressure causes a negative pressure in the alveoli and gas flows into the alveoli
-Incentive Spirometry
-Indications
-Any condition predisposing patient to development of atelectasis
-Presence of atelectasis -Presence of restrictive lung condition and pr dysfunctional diaphragm
-Incentive Spirometry
-Contradictions
-Patient who cannot follow directions/ coordinate treatment
-Incentive Spirometry
-Hazards/ complications
-Ineffective if not used correctly
-Hyperventilation in patients perform too fast -Tingling fingers, numbness around mouth, have patients to slow their breathing down -Bronchospasm -Pain
-Incentive Spirometry
-Devices
-Volume or flow oriented using visual cue/ indicator
-Simple to operate -Inexpensive
-Incentive Spirometry
-Giving treatment -Planning
-Assess and identify patients before surgery
-Determine desired outcomes
-Incentive Spirometry
Giving Treatment - Teaching and Intructing the Pts/ How many maneuvers per hour
-Effective patient teaching
-RT set initial effort and correct technique as required -Diaphragmatic breathing at slow to moderate rates -instruct in breath hold, very important -Rest between breaths -5-10 maneuvers per hour
-Incentive Spirometry
Giving Treatment Follow up
-Ensure correct technique
-Encourage use -Increase goal until at predicted value
-Intermittent Positive Pressure Breathing (IPPB)
-Application of inspiratory positive pressure to the spontaneously breathing patient as an intermittent or short term therapy
-Gas pushed into alveoli by positive pressure, followed by passive exhalation (mask or mouthpiece)
-Intermittent Positive Pressure Breathing (IPPB)
-Indications
-May be useful for atelectasis if patient doesn’t respond to IS or other positive pressure therapies
-Slow deep breaths with little patient effort followed by inspiratory hold
-Intermittent Positive Pressure Breathing (IPPB)
-Contraindications
-Untreated pneumothorax, recently oral/ facial surgery
-Relative contraindications -ICP>15mmHg -Active hemoptysis -Hemodynamic instability
-Intermittent Positive Pressure Breathing (IPPB)
-Hazards and complications
-Barotrauma
-Gastric distention -respiratory alkalosis, breathing too fast’ -Nosocomial infection -Nausea -Patients with high resp rate (tachypnea) should not use IS or IPPB -
-CPAP
-Continuous positive airway pressure- set pressure during both inhalation and exhalation
-Intermittent CPAP- used to treat atelectasis -Exact mechanism to treat atelectasis is unknown -recruitment of alveoli -Decreased WOB -Improved distribution of ventilation -Increase in efficiency of secretion removal
EZPAP
Coanda effect
-A positive airway pressure device that is used as lung expansion therapy
-Its connected to a flowmeter (ait of O2) adjusted to a flow of 5-10 LPM -EZPAP amplifies the input of air or oxygen by approximately four times by taking advantage of thee Coanda effect -Flow is adjustable until the desired expiratory airway pressure is reached -The patient is instructed to breathe normally through a mouthpiece or mask -Added benefit that neb tx can be given simultaneously
-Lung expansion Therapy
-Selecting appropriate lung expansion modality
-Best is always safest, simplest, most effective for the patient -Patient must be alert or will need to do IPPB -For IS- Patient must be alert or will need to do IPPB -If patient has excess secretions , use PEP therapy -Last resort, intermittent CPAP therapy
-Bronchial Hygiene Therapy
-Normal Airway Clearance
-Patient airway
-Functioning Mucociliary escalator -From larynx through respiratory bronchioles -Mucus goblet cells, submucosal glands, Clara cells, fluid from tissues which move into airways
-Bronchial Hygiene Therapy
-Effective cough
-Phase one, irritation (inflammatory, mechanical, chemical, or thermal)
-Phase two- inspiratory (normally 1-2L in adult) -Phase three, compression (glottic closure and forceful contraction of respiratory muscles) -Phase four- expulsion release as glottis opens (Cough)
-Bronchial Hygiene Therapy
-Abnormal airway clearance
-Impairment of normal clearance
-Anesthesia/ Narcotic analgesics, pain, restrictive lung disease, respiratory or abnormal muscle weakness or disease, artificial, airway obstructions, CNS depression/ Nerve damage, over distention of lungs/ inadequate lung recoil
-Bronchial Hygiene Therapy
-Abnormal airway clearance
Retained secretions
-Mucus plugging
-Infectious process if pathogens present -inflammation response=damage to tissues and increase mucus production
-Bronchial Hygiene Therapy
-Abnormal airway clearance
-Inspissated secretions
disease process or bypassed upper airway (Inadequate humidification)
-Bronchial Hygiene Therapy
-Abnormal airway clearance
-Diseases contributing to abnormal clearance
-Internal obstruction or external compression of airways
-Foreign bodies, tumors, thoracic deformities, bronchospasm, mucus plugging, obesity
-Cystic fibrosis
-Ciliary dyskinetic syndrome
-Bronchiectasis
-Musculoskeletal and neurological disorders
-Bronchial Hygiene Therapy -Indications for Therapy
-Acute conditions
-Copious secretions, acute respiratory failure with signs of retained secretions, acute lobar atelectasis
-Not helpful for
-Acute exacerbation of COPD, pneumonia without significant sputum production, uncomplicated asthma
-Indications for Therapy
-Chronic conditions
if sputum is produced
-Cystic fibrosis, bronchiectasis, chronic bronchitis- if sputum production is . 25-30ml per day
-Indications for Therapy
-Prevent retention of secretions
-Prevent retention of secretions
-Body positioning and patient mobilization’
-Determining the need
-Adequate patient assessment, CXR often a useful tool
Methods for Bronchial Hygiene
• Five methods
- 1) Postural drainage therapy (turning, percussion, and vibration), 2)coughing, 3)positive airway pressure therapy, 4)high-frequency compression/oscillation, IPV, 5)mobilization and exercise
• These five methods can be used alone or in combination with one another
Postural Drainage Therapy
turning/ contraindications
• Use of gravity and mechanical means to mobilize secretions
• Includes turning, percussion, and vibration (often referred to as CPT, PPD or pulmonary toileting)
• Turning
- Rotation of the body along a longitudinal axis
- Patient may do on own, have help, or be in a specialized bed
- Supine vs. prone
- Two absolute contraindications
• Unstable spine
• Traction of arm abductors
Postural Drainage Therapy
• Relative contraindications of positioning
- Severe diarrhea, rise in ICP, drop in BP of >10%, severe agitation, worsening dyspnea, hypoxia, cardiac arrhythmias
Postural Drainage Therapy
• Hazards and complications
- Hypoxemia, pain or injury to muscles, ribs, spine, vomiting and aspiration, plumbing problems - ventilator circuit disconnect, aspiration of condensation in ventilator circuit, IV lines, urinary catheters, chest tubes
Postural Drainage Therapy
• Proning
- Used in treatment of patients with ALI (acute lung injury)
- Improves oxygenation without hurting hemodynamics
- Not shown to improve survival
- Improvement in blood flow/recruitment of atelectatic areas
- Good lung down phenomenon- gravity takes blood to area of best ventilation
Postural Drainage Therapy Gravity/ Held Position time/ Sputum Production
• Use of gravity to help move secretions from distal areas into central airways; remove by suction or cough
• Place segmental bronchus in a vertical position relative to gravity
• Positions
- Held 5-10 minutes (per position)
- Modified as patient tolerates
• Most useful if patient is producing 25-30ml/day of sputum
• Not successful without adequate hydration
Postural Drainage Therapy • Technique
- Identify proper lobes/segments
• Physician order, CXR, breath sounds, may need to modify position
- Schedule before or 1-2 hours after eating
- Coordinate treatment times with pain meds
- Monitor all lines attached to patient for pulling/disconnection
- Pre-treatment assessment
• Vital signs
• Pulse Oximetry- should be monitored throughout therapy
• Auscultation
Positions (see handout)
- Head down - at least 12-18 inches
- Support all joints and bony areas with pillows/towels
- Maintain positions for 5-10 minutes as tolerated
- Allow rest between positions
- Discourage strong coughing in head down positi
- Continually monitor patient for any problems
Postural Drainage Therapy
• Post treatment assessment
- See above plus subjective responses
- Breath sounds may worsen after therapy
- Reevaluate therapy at least every 48-72 hours
Postural Drainage Therapy
• Documentation
- All positions used
- Time in each position
- All assessment - pre and post
- Sputum production - amount, color, consistency
- Follow up 1-2 hours later with patient/nurse
Postural Drainage Therapy
• Contraindications for CPT/PPD positioning
- Absolute contraindications
• Head and neck injury until stabilized
• Active hemorrhage or hemo-dynamically unstable
Postural Drainage Therapy
- Relative contraindications
• ICP > 20 mmHg, active hemoptysis, pulmonary embolism, rib fracture - with or without flail chest, large pleural effusion, CHF, confused or combative patient, distended abdomen, uncontrolled airway at risk for aspiration
Postural Drainage Therapy
• Hazards/Complications
- Hypoxemia, increased ICP, acute hypotension, pulmonary hemorrhage, pain or injury to muscles, ribs, spine, vomiting/aspiration, bronchospasm, and arrhythmias
- NOTE: If negative patient response - stop therapy, return patient to original position, stay with patient until STABILIZED, consult physician (take other steps as needed - place patient on 02 and adjust accordingly if hypoxic, suction and clear airway if vomiting, etc.)
Percussion and Vibration
• Application of mechanical energy to the chest wall by hand or other electrical/pneumatic device
• Augments secretion clearance
• Percussion - jar secretions loose/Vibration - move secretions toward central airways
Percussion and Vibration
• Manual percussion
- Cupped hands with fingers and thumb closed
- Traps cushion of air between chest and hands
- Rhythmically strike in a waving motion, alternating both hands with elbows partially flexed and wrists loose
- Percuss back and forth in a circular area for 3-5 minutes
- Avoid tender areas or bony areas
- Slower, relaxed rate are tolerated by patient and therapist
Percussion and Vibration
• Manual vibration
- Sometimes used with percussion but is limited to exhalation
- Lay one hand on the chest wall over the involved area and place the other hand over top
- After patient takes a deep breath, exert slight-to-moderate pressure and initiate a rapid vibratory motion of the hands through exhalation
Percussion and Vibration
• Mechanical percussion and vibration
- Electrical and pneumatic devices
- Have a frequency and force control knob
- Potential problems
• Noise, excess force, mechanical failure, no evidence they are better than RT, but these don’t tire out RT
Coughing Techniques
Coughing Techniques
• Effective cough is an essential component of all bronchial hygiene therapy
• Directed cough
- Deliberate maneuver to mimic a spontaneous cough
- Cannot make a person clear secretions if no sputum is present
- Clears from central and NOT peripheral airways
- Standard technique
• First establish clinical need
• Assess patient for factors that could limit success of directed cough
- Neurological factors, uncooperative patient, pain or fear of pain, systemic dehydration, CNS depression, COPD or restrictive disorder - may limit ability to generate an effective cough
Coughing Techniques - Positioning
• Sitting position preferred or semi-fowlers if unable to sit
- Breathing control (technique) for directed cough
• Instruct patient to take a deep breath, then hold the breath, using abdominal muscles to force air against a closed glottis the explosive release as glottis opens
• Have patient take several deep breaths before next cough effort
Coughing Techniques • Modifications in technique
Splinting - place hand or pillow over incision site and apply gentle pressure while coughing
- Manually assisted cough - external application of pressure to chest cage or epigastric region coordinated with forced exhalation
Coughing Techniques • Forced Expiratory Technique - Huff Cough
- Sharp exhalations from high to mid lung volumes through an open glottis
- To keep glottis open - patient says “huff” during expiration
- Still important to inhale using diaphragm and rest after cough
Coughing Techniques • Mechanical Insufflation-Exsufflation (MIE)
Cycles, followed by normal breathing/ Pressures
- Known as the cough assist
- Device that inflates the lungs with positive pressure followed by a negative pressure to simulate a cough
- Treatment consists of 5 cycles followed by 20-30 seconds of normal breathing
- For each cycle, the inspiratory pressure is 25-35 cmH20 for 1-2 seconds followed by expiratory pressure of -30 to -40 cmH20 for 1-2 seconds
- Can be used with a mask, or mouthpiece
- Shown effective in patients with neuromuscular disease
Positive Expiratiry Pressure (PEP)
• Active exhalation against a variable flow resistance
- Positive Pressure during exhalation using a one-way expiratory flow resistor…using a mask or mouthpiece
- Expiratory flow resistor keeps end expiratory pressure from falling back to zero
- Expiratory pressures range from 5-20 cmH20 at mid exhalation
Positive Expiratiry Pressure (PEP)
• Indications for treatment
- Reduce air trapping in asthma and COPD
- Mobilize retained secretions for CF and chronic bronchitis
- Optimize delivery of bronchodilators
Positive Expiratiry Pressure (PEP)
• Contraindications
- ICP > 20 mmHg, hemoptysis, recent surgery to mouth/face/skull, untreated pneumothorax, nausea and vomiting
- Discontinue treatment if: sinusitis, epistaxis, or middle ear infection
Positive Expiratiry Pressure (PEP)• Hazards and complications
- Pulmonary barotrauma, hemodynamic compromise, skin breakdown and discomfort, air swallowing/vomiting/aspiration
Positive Expiratiry Pressure (PEP) • Technique for PEP
- Patient sitting comfortably upright
- Adjust the expiratory resistor to the prescribed setting
- Larger than normal breath but not to TLC
- Using a tight seal, exhale gently (not forcefully) to a pressure of 5-20 cmH2O (mask or mouthpiece)
- Exhalation should be three times longer than inhalation
- Should perform 10-20 PEP breaths and 2-3 huff coughs
- Each session is 10-20 minutes and should be performed 1-4 times per day
High Frequency
High Frequency Conpression/ Oscillation
• Rapid vibratory movement of small volumes of air back and forth in the respiratory track
• High frequencies measures in Hz
High Frequency Conpression/ Oscillation
• Two methods
- External-high frequency chest wall compression
(HFCWC)
- Applied to Airway
• Flutter
• Intra-pulmonary percussive ventilation (IPV)-see video on blackboard
High Frequency Conpression/ Oscillation
• HFCWC
- Two part system
• Variable air-pulse generator
• Inflatable vest that covers patients torso
- 5-25Hz, 20 minute sessions, 1-6 times per day depending on need
- Well known system - The Vest Airway Clearance
System
High Frequency Conpression/ Oscillation
• IPV (Intrapulmonary percussive ventilation)
- Creates positive changes by injecting short, rapid inspiratory flow pulses into the airway opening and relies on chest wall recoil for passive exhalation
- 300-400 cycles per minute (1.7-5Hz for 15-20 minutes)
Airway Oscillating Devices
• Alternative methods for bronchial hygiene
• Produce PEP with oscillations in the airway
• Promote patient independence and better compliance
Airway Oscillating Devices• Flutter valve
- Heavy steel ball sits in the bowl of “pipe” like device
- As patient exhales, ball creates positive pressure of
10-25 cmH20
- Pipe angle causes ball to “flutter” back and forth at about 15Hz
- Disadvantage - position dependent, movement slightly upward or downward changes the vibration frequency
Airway Oscillating Devices• Acapella “the pickle”
- Uses a counterweighted plug and magnet to create airflow oscillations during expiratory flow
- Has an adjustable resistor
- Not position dependent and is considered easier to use for
patients(can give neb thru device)
Airway Oscillating Devices• The Quake
- Manually rotating handle that creates the oscillations
- The frequency is controlled by how quickly the handle is rotated
- Slow = low-frequency oscillation and high expiratory
pressure
- Fast = high-frequency oscillation and low expiratory
pressure
- Not position dependent
