Lung Expansion Therapy PDF

LUNG EXPANSION THERAPY Shanayra I. Jayaji, RTRP TYPES OF ATELECTASIS A. GAS ABSORPTION ATELECTASIS- Gas distal to an obstruction is absorbed by blood passing through the pulmonary capillaries, which eventually causes partial collapse of the nonventilated alveoli....

LUNG EXPANSION THERAPY Shanayra I. Jayaji, RTRP TYPES OF ATELECTASIS A. GAS ABSORPTION ATELECTASIS- Gas distal to an obstruction is absorbed by blood passing through the pulmonary capillaries, which eventually causes partial collapse of the nonventilated alveoli.  LOBAR ATELECTASIS- when ventilation is compromised in a lobar bronchi B. COMPRESSION ATELECTASIS- restricts or inhibits deep inhalation  This situation is common with the following conditions:  General anesthesia  When deep breathing is painful (broken ribs or abdominal or thoracic surgery)  Morbidly obese patients.  Weakening or impairment of the diaphragm  Compression atelectasis also results from fluid overload  Persistent breathing in small tidal volumes  Most common type of atelectasis for hospitalized patients  May occur in combination with gas absorption atelectasis FACTORS ASSOCIATED WITH CAUSING ATELECTASIS  Patients under heavy sedation  Patients with neuromuscular disorders  Obesity  Patients who undergone upper abdominal or thoracic surgery (The closer the incision is to the diaphragm, the greater the risk for postoperative atelectasis)  Impairment of the function of pulmonary surfactant  Ineffective cough  Patients with a history of lung disease that causes increased mucus production (e.g., chronic bronchitis) are most prone to develop complications in the postoperative period.  History of cigarette smoking CLINICAL SIGNS OF ATELECTASIS  The physical signs of atelectasis may be absent or very subtle if the patient has minimal atelectasis  As atelectasis progress, RR increases  Breathing pattern: rapid, shallow breathing  Via auscultation: fine, late inspiratory crackles; diminished breath sounds  Egophony has also been considered to be present if, when asked to say the letter “E,” the patient sounds to the practitioner as if he or she were saying “Aaay.  CXRAY: Increased opacity, shifting of the trachea to the affected side.  Atelectasis can occur in any patient who cannot or does not take deep breaths periodically and in patients who are restricted to bed rest for any reason NORMAL CXRAY ATELECTASIS CXRAY  Lung expansion therapy corrects atelectasis by increasing the PAL gradient; this can be accomplished by deep spontaneous breaths or by the application of positive pressure Where: PAL= Transalveolar pressure Palv= Alveolar pressure Ppl= Pleural pressure  The greater the PAL gradient, the more the alveoli expand.  The PAL gradient can be increased by either: (1) decreasing the surrounding Ppl or (2) increasing the Palv  To decrease Ppl, the patient can take a deep inspiration.  To increase the Palv, positive pressure can be applied to the lungs.  All lung expansion therapies use one of these two approaches. LUNG EXPANSION THERAPY Encompasses a variety of respiratory care procedures designed to prevent or treat atelectasis. These techniques are: 1. Incentive spirometry 2. Intermittent Positive Pressure Breathing 3. Positive Expiratory Pressure 4. Continuous Positive Airway Pressure - The common purpose of these procedures is to improve pulmonary function by maximizing alveolar recruitment and optimizing airway clearance. - Main goal of lung expansion therapy is to increase FRC (to stimulate deep breath and sigh) For a patient with minimal risk of postoperative atelectasis, deep breathing exercises, frequent repositioning, and early ambulation are usually effective EARLY MOBILIZATION  It is better for the overall recovery of patients to get them out of bed and provide early ambulation.  Pulmonary complications of immobility include: development of atelectasis, pneumonia, and pulmonary emboli (PE)  As the patient changes body position, his or her breathing changes, as does the gas distribution within the lung. Improvements in 1. INCENTIVE SPIROMETRY The purpose of IS is to coach the patient to take a Sustained Maximal Inspiration (SMI) resulting in a decrease pleural pressure and maintaining the patency of alveoli at risk for closure. IS devices are designed to mimic natural sighing by encouraging patients to take slow, deep breaths simulating a yawn or sigh INDICATIONS  Presence of pulmonary atelectasis  Presence of conditions predisposing to atelectasis o Upper abdominal surgery and thoracic surgery o Surgery in patients with COPD  Presence of a restrictive lung defect associated with quadriplegia or dysfunctional diaphragm. CONTRAINDICATIONS  Patients cannot be instructed or supervised to ensure appropriate use of device.  Patient cooperation is absent or patient is unable to understand or demonstrate proper use of device.  Patients unable to take a deep breath (VC of less than 10 mL/kg) HAZARDS AND COMPLICATIONS  Hyperventilation and Respiratory Alkalosis- Ask the patient to pause longer between deep breaths  Discomfort secondary to inadequate pain control  Pulmonary barotrauma  Exacerbation of bronchospasm  Fatigue NOTES: Respiratory Alkalosis is the most common complication of lung expansion therapy. A patient with respiratory alkalosis exhibits dizziness and numbness around the mouth Incentive spirometry is not a single modality treatment. In able for it to be effective, it is used with other procedures like early mobilization, deep breathing exercises, and directed coughing. INCENTIVE SPIROMETER DEVICES A. Volume-oriented incentive spirometer Indicates inspiratory volume my moving piston/bellows B. Flow-oriented incentive spirometer As inspiratory flow increases, each ball will begin to rise - Both flow-oriented and volume-oriented devices attempt to encourage the same goal for the patient: an SMI effort to prevent or correct atelectasis. There is no benefit of one type of IS over the other Steps in Performing Incentive Spirometry 1. Explain the procedure to the patient. 2. Place the patient in a semi-Fowler or Fowler position. 3. Instruct the postoperative patient to splint the incision site when inhaling. Assist the patient when necessary. 4. Then instruct the patient in the following steps for therapy: a. Hold the spirometer in an upright position or place on a flat surface. b. Exhale normally c. Place the mouthpiece in the mouth and keep lips sealed tight. d. Inhale slowly and as deeply as possible (inspiratory capacity). Hold the breath for 5 to 10 seconds, then remove the mouthpiece and exhale normally. e. Rest and breathe normally for approximately 30 seconds to 1 minute to avoid hyperventilation. f. Repeat the maneuver five to ten times per waking hour (may vary) g. Instruct patient to cough following therapy. 5. Document the procedure and the patient response to therapy in the patient chart. 6. Evaluate the patient periodically to ensure that a proper breathing technique is being used. 2. INTERMITTENT POSITIVE PRESSURE BREATHING  A specialized form of Noninvasive ventilation  Is a short-term breathing treatment (15 minutes per treatment) where increased breathing pressure is delivered via ventilator to help prevent or treat atelectasis, clear secretions or deliver aerosolized medications.  Pressure is applied during inspiration, exhalation is passive. (slow, deep breaths held at end-inspiration)  May IPPB be delivered should not betoused intubated and non-intubated patients as a single treatment modality for a patient with absorption atelectasis because of excessive airway secretions. INDICATIONS:  PATIENTS WHO ARE UNRESPONSIVE TO OTHER MODALITIES OF LUNG EXPANSION  Presence of clinically significant pulmonary atelectasis  Inability to clear secretions adequately  The need to deliver aerosol medication for patients who cannot take a deep breath (esp. for patients with ventilatory muscle weakness or fatigue= VC of less than 10 mL/kg) Some clinicians oppose the use of IPPB in the treatment of severe bronchospasm however, a careful, closely supervised trial of IPPB as a medication delivery device when treatment using other techniques has been unsuccessful  CONTRAINDICATIONS ABSOLUTE Tension pneumothorax (untreated) RELATIVE Intracranial pressure (ICP) > 15 mm Hg Hemodynamic instability Nausea Recent facial, oral, or skull surgery Air swallowing Tracheoesophageal fistula Active untreated tuberculosis Recent esophageal surgery Radiographic evidence of bleb Active hemoptysis Singulation (hiccups)  Hazards and  Hyperventilation Complications hypocapnia respiratory alkalosis  Impedance of venous return  Barotrauma, pneumothorax  Increased airway resistance- give bronchodilators before therapy  Hemoptysis  Gastric distention  Impaction of secretions- Adequate humidification  Hypoventilation Hypercapnia respiratory acidosis  Exacerbation of hypoxemia  Air trapping, auto-PEEP, overdistended alveoli WHAT TO DO? (for relative contraindications) -Use the lowest possible pressure to improve tidal volume effectively -Allowing the patient adequate expiratory time -Allowing the patient to rest if needed WHAT TO DO? (for hazards and complications) -Triple S rule [ STOP the treatment, STAY with the patient, STABILIZE the patient] -Inform the physician NOTE: During IPPB treatment. Always check the vital signs. If the pulse rate increases 20 beats/min from the baseline then stop the treatment and inform the physician  PROBLEMS WITH IPPB AND CORRECTIVE ACTIONS: 1. THE PATIENT IS HAVING DIFFICULTY CYCLING THE MACHINE INTO THE INSPIRATION  Adjust sensitivity -1 to-2 cmH2O  Make sure machine is plugged into the wall gas outlet  Ensure connections are tight  Ensure that the lips are tightly sealed 2. PX COMPLAINS OF DIIZZINESS AND TINGLING IN THE EXTREMITIES DURING TREATMENT BUT HAS NO INCREASE HEART RATE  Instruct patient to breathe slower and to pause longer between breaths 3. PX HEART RATE INCREASES >20 BEATS PER MIN. DURING TREATMENT  Stop treatment and notify the physician  PROBLEMS WITH IPPB AND CORRECTIVE ACTIONS: 4. AS THE PX INHALES, THERE IS NO NEBULIZATION OF THE MEDICATION  Ensure that the capillary tube is connected  Ensure that there is medication in the nebulizer  Ensure that the nebkit is in the upright position 5. DURING INSPIRATION THE MANOMETER NEEDLE STAYS IN THE NEGATIVE AREA DURING THE FIRST HALF AND THEN RISES SLOWLY DURING THE LAST HALF  Increase machine flow rate 6. IPPB MACHINE REPEATEDLY CYCLES ON, SHORTLY AFTER THE PATIENT HAS BEGUN EXHALATION  Decrease machine sensitivity NOTE: TOO HIGH (-1 above) – SENSITIVE (MADALI I-TRIGGER) TOO LOW (– 2 below) - NOT TOO SENSITIVE ( MAHIRAP I-TRIGGER) ADDITIONAL INFO..  Pressure is applied during inspiration  IPPB should not be the first option  IPPB is expensive to implement and maintain  Mechanical effects of IPPB are short-lived,lasting an hour after treatment  Delivery of a therapeutic medication dose via IPPB may require as much as a tenfold increase in medication amount when compared to MDIs (according to AARC CPG)  The optimal breathing pattern to reinflate collapsed lung units with IPPB consists of slow, deep breaths that are sustained or held at end-inspiration 3. POSITIVE AIRWAY PRESSURE (PAP) ADJUNCTS A. Positive Expiratory Pressure (PEP) devices The good thing about PEP is that you can use it for lung expansion, for airway clearance as well as for aerosol delivery (not all PEP device could deliver aerosol) PEP therapy should not be used on patients who cannot tolerate any increased work of breathing, are hemodynamically unstable, or suffer from bullous emphysema, high ICP, untreated pneumothorax, sinusitis, epistaxis, or middle ear problems. Three types of PEP devices: a. Flow resistor- TheraPEP b. Threshold resistor- EzPAP c. Vibratory PEP- most common are Flutter valve and acapella 1. TheraPEP 3. Flutter valve 4. Acapella device NOTE: All of these devices typically generate between 6 and 25 cm H2O pressure during exhalation and allow unrestricted inspiration. 2. EzPAP  If a PEP device fails to generate pressure, the most likely problem is a leak. High pressures also can occur in these devices if the outlet port is obstructed PEP therapy cannot be used in young children (