Lung Expansion Intro to Lung Expansion 2024 PDF

Lung Expansion  Pulmonary complications ◼ Pulmonary complications are the most common serious problems seen in patients who have undergone thoracic or abdominal surgery. ◼ Many disease states also lead to complications. ◼ Such complications include atelectasis, pneumonia, a...

Lung Expansion  Pulmonary complications ◼ Pulmonary complications are the most common serious problems seen in patients who have undergone thoracic or abdominal surgery. ◼ Many disease states also lead to complications. ◼ Such complications include atelectasis, pneumonia, and acute respiratory failure.  Pulmonary complications ◼ These respiratory problems can be minimized or avoided if proper respiratory therapy is implemented during the pre-operative period. ◼ The most common form of respiratory therapy utilized in high-risk patients is lung expansion therapy.  Lung expansion therapy ◼ Although atelectasis can occur from a large variety of problems, we will focus on the two primary types associated with postoperative or bedridden patients: (1) resorption atelectasis (2) passive atelectasis. Intentionally Left Blank  Resorption Atelectasis ◼ Resorption atelectasis occurs when mucus plugs are present in the airways and block ventilation of the affected region. ◼ Gas distal to the obstruction is absorbed by the passing blood in the pulmonary capillaries, which causes the non-ventilated alveoli to partially collapse (ATELECTASIS).  Passive Atelectasis. ◼ Passive atelectasis is primarily caused by persistent use of small tidal volumes by the patient. Common when general anesthesia is given, with sedatives, excessive bed rest, and when deep breathing is painful. ◼ Weakening or impairment of the diaphragm also can contribute to passive atelectasis  Passive Atelectasis ◼ Passive atelectasis results when the patient does not periodically take a deep breath to fully expand the lungs. ◼ It is a common cause of atelectasis in the hospitalized patient. ◼ It is very prevalent with abdominal and thoracic surgeries.  Lobar Atelectasis ◼ A severe form of atelectasis, Lobar atelectasis occurs in about 5% of patients who have undergone lung resection. ◼ Often centers around a large mucus plug but it can be the result of multiple factors.  Atelectasis ◼ Atelectasis can occur in any patient who cannot or does not a take deep breath periodically. Lung Volumes & Capacities  Decrease in Functional Residual Capacity (FRC) ◼ The decrease in FRC is associated with alveolar collapse, most often in the basal or dependent portions of the lung. ◼ Because perfusion remains unchanged, a ventilation/perfusion (v/q) mismatch results, causing arterial hypoxemia.  RULE OF THUMB ◼ The closer the incision is to the diaphragm the greater the risk for postoperative atelectasis.  Lung expansion therapy ◼ Most postoperative patients also have problems coughing effectively because of their reduced ability to take deep breaths. ◼ Coughing can be painful, so it is helpful to "splint" the incision site when coughing. ◼ An ineffective cough impairs normal clearance mechanisms and increases the likelihood of retained secretions.  Pre-Surgery Screening ◼ Upper abdominal or thoracic surgery in any patient could suggest possible atelectasis. ◼ The history of chronic lung disease and/or cigarette smoking provides additional evidence that the patient is prone to respiratory complications following major surgery or prolonged bed rest. ◼ OSA can also lead to complications.  Physical signs of atelectasis ◼ When the atelectasis involves a more significant portion of the lungs, the patient’s respiratory rate will increase proportionally. ◼ Fine, late-inspiratory crackles may be heard over the affected lung region. ◼ These crackles are produced by the sudden opening of distal airways with deep breathing.  Physical signs of atelectasis ◼ Bronchial-type breath sounds may be present as the lung becomes more consolidated with atelectasis. ◼ Diminished breath sounds are common when excessive secretions block the airways and prevent transmission of breath sounds. Intentionally Left Blank  Physical signs of atelectasis ◼ Atelectasis alone does not cause the patient to develop a fever unless pneumonia is also present.  XRAY Chest Film ◼ The chest film is often used to confirm the presence of atelectasis. ◼ The atelectatic region of the lung will demonstrate increased opacity. ◼ Evidence of volume loss is present in those patients with significant atelectasis.  XRAY Chest Film ◼ Indirect signs include elevation of the diaphragm; shift of the trachea, heart, or mediastinum; pulmonary opacification; narrowing of the space between the ribs; and compensatory hyperexpansion of the surrounding lung.  Negative Inspiration Pressure ◼ A spontaneous deep inspiration increases the PL gradient by decreasing pressure. ◼ The application of positive pressure to the lungs increases the PL gradient by raising the pressure inside the alveoli. Negative Inspiration Pressure  Lung Expansion Therapy ◼ IS or SMI has been the mainstay of lung expansion therapy for well over a decade. SMI is designed to mimic natural sighing by encouraging patients to take slow, deep breaths. (Natural sigh 6 to 9 times an hour). ◼ SMI is performed using devices that provide visual cues to the patients when the desired flow or volume has been achieved.  Incentive Spirometry ◼ The desired volume and number of repetitions to be performed is initially set by the RT or other qualified caregiver. ( Good number is 5 – 10 times an hour; 20 times every two hours). ◼ The inspired volume goal is set on the basis of predicted values or observation of initial performance. ◼ Predicted values are based on age, height, and sex. Incentive Spirometry Values  Physiological Basis of Incentive Spirometry (IS) ◼ The basic maneuver of IS is a sustained, maximal inspiration (SMI). ◼ A SMI is a slow, deep inhalation from the FRC up to (ideally) the total lung capacity, followed by a 5 to 10 second breath hold. ◼ A SMI is thus functionally equivalent to performing an inspiratory capacity (IC) maneuver, followed by a breath hold. Reasons for Poor Gas Exchange.  Physiological Basis of IS ◼ During the inspiratory phase of spontaneous breathing, the drop in PL pressure caused by expansion of the thorax is transmitted to the alveoli. ◼ Thus, assisting in maintaining open alveoli, recruiting collapsed alveoli and correcting atelectasis.  Indications for IS ◼ The primary indication for IS is to treat existing atelectasis. ◼ IS may also be used as a preventive measure when conditions exist that make the development of atelectasis likely. ◼ IS devices can be used to monitor lung function in the postoperative period because there is good correlation between IS performance and VC measurement.  Indications for IS Box 42-1 (pg. 941)  Contraindications For IS Box 42-1 (pg. 940)  Hazards / Complications of IS IS, is a simple and relatively safe modality. For this reason, contraindications are few…  Hazards / Complications of IS Box 42-1  Hazards / Complications of IS ◼ Acute respiratory alkalosis (hyperventilation) is the most common problem and occurs when the patient performs IS too rapidly. ◼ Dizziness and numbness around the mouth and finger- tips are the most frequently reported symptoms associated with respiratory alkalosis. ◼ This problem is easily corrected by spacing out the efforts (about 30 seconds apart).  Hazards / Complications of IS ◼ Discomfort with deep inspiratory efforts secondary to pain is usually the result of inadequate pain control in the postoperative patient. ◼ You may have the Pt activate their self- administered pain medication before starting - PCA pump.  The equipment needed for IS ◼ IS devices can generally be categorized as volume- or flow-oriented. ◼ True volume-oriented devices actually measure and visually indicate the volume achieved during an SMI.  The equipment needed for IS ◼ Flow-oriented devices measure and visually indicate the degree of inspiratory flow. ◼ Flow can be equated with volume by assessing the duration of inspiration in time (flow x time = volume). ◼ No evidence to date indicates that one type (Flow or Volume) is more beneficial than the other in treating atelectasis.  Administering IS ◼ The successful application of IS involves three phases: ◼ Planning, implementation, and follow-up. ◼ Planning the need for IS should be determined by careful patient assessment. Once the need is established, planning for IS should focus on selecting explicit therapeutic outcomes.  Implementation ◼ Successful IS requires effective patient teaching. The RT should set an initial goal (e.g., a certain volume) that is attainable but requires some moderate effort. ◼ Setting an initial goal too low or too high for the patient results in little incentive, and may result in an ineffective maneuver, at least initially.  Implementation ◼ Observe the patient performing the initial inspiratory maneuvers and make sure the patient uses the correct technique. ◼ Correct technique calls for diaphragmatic breathing at slow-to-moderate inspiratory flows. ◼ Demonstration is probably the most effective way to assist patient understanding and cooperation.  Follow-Up ◼ As always, assessing the patient’s performance is vital to ensuring achievement of goals. ◼ IS Protocols are effective gauges to follow in monitoring patient outcomes.  Instructing IS Step By Step ◼ The Order ◼ Gather the equipment ◼ Prepare the Equipment ◼ Prepare the Patient ◼ Pain medicine, Position (if able to move), Alertness (how awake are they)  Figure Inspiratory Capacity ◼ Male 60” tall = 106. Then add… ◼ 6 lbs for every inch over 60” ◼ Divide / 2.2 = kg ◼ Multiply 45 mls x kg = Insp. Capacity ◼ IC is the maximum volume which can be inhaled after a maximal exhalation. Inappropriate Therapy is < 15 ml / kg  Figure Inspiratory Capacity ◼ Female 105 = 60” ◼ 5 lbs for every inch over 60” / 2.2 = kg ◼ 45 mls x kg = Insp. Capacity Inappropriate Therapy is IC < 15 ml / kg  Alternate IBW Formula Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.  Figure Inspiratory Capacity ◼ Female 63” what is the IC? ◼ 105 + ( 5 x 3 [every inch over 60” ] ) = 120 IBW in pounds / 2.2 (to make kgs) = 54.5 IBW kgs x 45 = Insp. Capacity = 2454mls x 30% IC = 736 ml - (IS Goal)  Figure Inspiratory Capacity ◼ Male 71” what is the IC? ◼ 106 + ( 6 x every inch over 60” [ 11 ] ) = 172 IBW in pounds / 2.2 (to make kgs) = 78 IBW kgs x 45 = Insp. Capacity = 3518 mls x 30% VC = 1055 mls  Figure Inspiratory Capacity ◼ Female 73” what is the IC? ◼ 105 + ( 5 x every inch over 60” [ 13 ] ) = 170 IBW in pounds / 2.2 (to make kgs) = 77 IBW kgs x 45 = Insp. Capacity = 3477 mls x 30% VC = 1043 mls  Therapy Mnemonic ◼ O – G – P – A – E – R & WASH ◼ O = Orders ◼ G = Gather the required equipment ◼ P = Prepare Equipment and Pt (PAIN CONTROL) ◼ A = Assess the pt ◼ E = Evaluate the Therapy / Tx ◼ R = Record and Report ◼ Wash Hands before and after all pt contact.  Instructing IS Step By Step ◼ Assessment ◼ Orientation - able to follow commands, able to reproduce what you have shown, able to hold on own ◼ Evaluate ◼ Performance, effort based on predicted, pain level, SpO2, HR, RR, BS. ◼ CAN THEY PERFORM ON OWN or NEED CONTINUED SUPEVISION  Instructing IS Step By Step ◼ Record and Report ◼ Chart results and findings ◼ Report and inform the nurse of the pt’s status ◼ FOLLOW – UP WASH HANDS BEFORE AND AFTER PT CONTACT Please review the RCP 120 Video emailed to you – ‘Incentive Spirometry.” (YouTube Video)