ret 2275 volume expasion therapy
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Volume Expansion Therapy (VET)
RET 2275
Respiratory Care Theory 2
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Volume Expansion Therapy (VET)
Volume Expansion Therapy AKA
Lung expansion therapy
Hyperinflation therapy
A variety or respiratory care modalitiesdesigned to prevent or correct atelectasisby augmenting lung volumes
Incentive Spirometry (IS) Intermittent Positive Airway Pressure (IPPB)
Continuous Positive Airway Pressure (CPAP)
Positive Expiratory Pressure (PEP)
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Volume Expansion Therapy (VET)
Atelectasis
Definition: alveolar collapse
Types:
Obstructive Caused by mucus plugging of airways
Passive
Cause by constant tidal breathing of small volumes
Common complication in postoperative patients
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Volume Expansion Therapy (VET)
The Sigh Mechanism
Definition:the automatic, periodic inhalation of a large
tidal volume to prevent passive atelectasis
Normally, a person sighs about 6-10 times per hour
Passive atelectasis can occur if this mechanism isimpaired or lost
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Volume Expansion Therapy (VET)
The Sigh Mechanism
Factors that can impairthe sigh mechanism
General anesthesia
Pain Pain medication
Decreased level of consciousness
Thoracic or upper abdominal surgery
Impaired diaphragmatic movement
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Volume Expansion Therapy (VET)
Sustained Maximal Inspiration (SMI)
A slow, deep inhalation form the FRC up to
(ideally) the total lung capacity, followed by a 5
10 second breath hold
Designed to mimic natural sighing
The negativealveolar & pleural pressuresreexpand collapsed alveoli and prevent the
collapse of ventilated alveoli
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Volume Expansion Therapy (VET)
Indications
Presence of pulmonary atelectasis
Presence of condition predisposing to
atelectasis Upper abdominal surgery
Thoracic surgery
Surgery in patient with COPD
Presence of a restrictive lung defect associated withquadriplegia and/or dysfunctional diaphragm
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Volume Expansion Therapy (VET)
Hazards & Complications of VET
Ineffective in absence of correct technique (may
require repeated instruction & coaching)
Hyperventilation
Exacerbation of bronchospasm
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Volume Expansion Therapy (VET)
Hazards & Complications of VET
Hypoxemia (if O2 therapy is interrupted)
Barotrauma (in emphysematous lungs)
Fatigue
Pain in postoperative patients
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Volume Expansion Therapy (VET)
Assessment of Need
Evidence of atelectasis based on physical exam & x-
ray findings
Upper abdominal or thoracic surgery
Presence of predisposing conditions
Presence of neuromuscular disease affecting therespiratory muscles
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Volume Expansion Therapy (VET)
Findings Consistent with Atelectasis
Diminished breath sounds & fine crackles in affectedarea
Fever
Tachypnea & tachycardia
Dull percussion note
Characteristic opacity on chest x-ray
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Volume Expansion Therapy (VET)
Incentive Spirometry Equipment
Device is only a visual aid
Importance is placed on patient performing the correct
maneuver
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Volume Expansion Therapy (VET)
Incentive Spirometry (IS)
Equipment
Volume IS
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Volume Expansion Therapy (VET)
Incentive Spirometry (IS)
Equipment
Flow oriented
(flow x time = volume)
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Volume Expansion Therapy (VET)
Incentive Spirometry (IS)
Administering IS
Physician order required
Instruct patient Importance of deep breathing
Demonstration is the most effective way to assist the
patients understanding and cooperation
Position patient
Sitting or semi-Fowlers
Semi-Fowlers Position
(Head elevated 30)
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Volume Expansion Therapy
Incentive Spirometry (IS)
Administering IS
RT should set initial goal (e.g. certain volume)
Should require some moderate effort Instruct patient to inspire SLOWLY and deeply
Maximizes distribution of ventilation
Ensure that the patient is using diaphragmatic breathing
Instruct patient to sustain maximal inspiratory
volume for 5 10 seconds followed by a normalexhalation
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Volume Expansion Therapy
Incentive Spirometry (IS)
Administering IS
Give the patient an opportunity to rest
Some patients need 30 seconds to one minute Helps prevent hyperventilation, dizziness, numbness
around the mouth, respiratory alkalosis
IS regimen should aim to ensure a minimum of 5 -
10 SMI maneuvers each hour
Once technique is mastered, minimum supervision isrequired
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Volume Expansion Therapy (VET)
Assessment of Outcome
Absence of or improvement in signs of atelectasis
Normal respiratory & heart rates
Afebrile
Absence of abnormal breath sounds
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Volume Expansion Therapy (VET)
Assessment of Outcome
Normal chest x-ray
Improved oxygenation (PaO2/SpO2)
Return of normal spirometric values
Improved respiratory muscle performance
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Volume Expansion Therapy
Incentive Spirometry (IS)
Charting IS
Pre-treatment vital signs
HR, RR, Breath sounds Initial goal
Example: 800 ml x 10 SMI
Patient toleration
Post-treatment vital signs
Patient education
See examples of charting notes on next slide
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Volume Expansion Therapy (VET)
Incentive Spirometry (IS) - Charting
Example of Chart Note:
1/31/06, 08:30 IS given to patient sitting in chair. HR = 80 - 72,
RR = 16 - 14, Breath sounds decreased at bases bilaterally, somefine crackles noted at end inspiration. Obtained IS goal of 2.0 L x 7
SMI. Patient has a dry, non-productive cough. Breath sounds
unchanged after treatment. Patient tolerated treatment without
incident.
Example of Pat ient Educat ion Note:Instructed patient regarding the importance taking deep breaths after
surgery. Demonstrated IS technique for patient. Patient verbalized
understanding of therapy and gave a return demonstration with IS.
Sy Big, MDC Student
Respiratory Care
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Volume Expansion Therapy (VET)
Important Points Regarding Use of IS
Verify that there is an indication for therapy
Effective patient teaching & coaching is essential
Demonstrate technique for patient
Teach splinted coughing
Place device within patients reach
Provide rest periods as necessary
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CPAP
Definition
The application of a
positive airway pressure
to the spontaneouslybreathing patient
throughout the
respiratory cycle at
pressures of 5 20 cm
H2O
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CPAP
Physiological Principles
CPAP elevates and maintains high alveolar and
airway pressures throughout the full breathing cycle.
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CPAP
Physiologic Principles - Equipment
The patient on CPAP breaths through a pressurized
circuit against a threshold resistor, with pressures
maintained between 5 20 cm H2O
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CPAP
Physiologic Principles - Equipment
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CPAP
Physiologic Principles
CPAP
Recruits collapsed alveoli via an increase in FRC
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CPAP
Physiologic Principles
CPAP
Recruits collapsed alveoli via an increase in FRC
Decreases work of breathing due to increased complianceor abolition of auto-PEEP
Improves distribution of ventilation through collateral
channels (e.g., Kohns pores)
Increases the efficiency of secretion removal
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CPAP
Indications
Postoperative atelectasis
Cardiogenic pulmonary edema
Refractory hypoxemia
PaO2
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CPAP
Contraindications
Hemodynamic instability
Hypoventilation
CPAP does not ensure ventilation
Nausea
Facial trauma
Untreated pneumothorax
Elevated intracranial pressure
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CPAP
Hazards and Complications
Increased work of breathing caused by the apparatus
Hypoventilation and hypercapnia
Patients with ventilatory insufficiency mayhypoventilate during application
Barotrauma
More likely in patients with emphysema and blebs
Gastric distention (CPAP pressures >15 cm H2O) Vomiting and aspiration in patients with an inadequate gag
reflex
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CPAP
Monitoring and Troubleshooting Patients must be able to maintain adequate excretion
of CO2 on their own
System pressure must be monitored Alarms need to indicate system disconnect or mechanical
failure
Masks may cause irritation and pain
Adequate flow to meet patients need
Flow initially set to 2 3 times the patients minuteventilation
Flow is adequate when the system pressure drops no morethan 1 2 cm H2O during inspiration
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CPAP
Patient Interfaces
Nasal Mask
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CPAP
Patient Interfaces
Fitting the Nasal Mask
Dorsum of nasal bridge Around the nasal alae
Mid philtrum
Use foam bridge
Prevents collapse of maskonto nose
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CPAP
Patient Interfaces
Fitting the Nasal Mask
DO NOT over tighten Tissue necrosis
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CPAP Tissue necrosis
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CPAP
Patient Interfaces
Full-Face Mask
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CPAP
Patient Interfaces
Fitting the Full-Face Mask
Dorum of nasal bridge
Surrounds nose/mouth
Rests below lower lip
DO NOT over tighten
Tissue necrosis
Foam bridge Prevents collapse of mask
onto nose
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CPAP
Nasal vs. Full-Face Mask
Nasal Masks More prone to air leaks (especially mouth
breathers) Use chin strap
Full-Face Mask Increase dead space
Risk of aspiration Claustrophobia
Interferes with expectoration of secretions,communication, eating
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CPAP
Patient Interfaces
Total Face Mask
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EZ-PAP
Lung expansion therapy
during inspiration and
PEP therapy during
exhalation
Used for the treatment orprevention of atelectasis
and the mobilization of
secretions
Aerosol drug therapymay be added to a PEP
session to improve the
efficacy of bronchodilator
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EZ-PAP
EZ-PAP
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EZ-PAP
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EZ-PAP with SVN
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IPPB
Definition
The application of inspiratory positive pressureto a spontaneously breathing patient as an
intermittent or short-term therapeutic modality
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IPPB
Definition
The delivery of a slow deep sustainedinspiration by a mechanical device providing
controlled positive pressure breath during
inspiration
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IPPB
Indications (AARC)
The need to improve lung expansion Treatment of atelectasis not responsive to other
therapies, (e.g., IS and CPT)
Inability to clear secretions adequately
Limited ventilation Ineffective cough
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IPPB
Indications (AARC)
Short-term nonivasive ventilatory support forhypercapnic patients
Alternative to intubation and continuous
ventilatory support
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IPPB
Indications (AARC)
The need to deliver aerosol medication When MDI or nebulizer has been unsuccessful
Patients with ventilatory muscle weakness or
fatigue
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IPPB
Contraindications (AARC)
Tension pneumothorax________________________________________
ICP > 15 mm Hg
Hemodynamic instability
Recent facial, oral or skull surgery
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IPPB
Contraindications (AARC)
Tracheoesophageal fistula Recent esophageal surgery
Active hemoptysis
Nausea
Air swallowing
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IPPB
Contraindications (AARC)
Active, untreated TB Radiographic evidence of bleb
Singulus (hiccups)
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IPPB
Hazards (AARC)
Increase airway resistance (Raw) Barotrauma, pneumothorax
Nosocomial infection
Hyperventilation (hypocapnia)
Hemoptysis
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IPPB
Hazards (AARC)
Hyperoxia when O2 is the gas source Gastric distention
Secretion impaction (inadequate humidity)
Psychological dependence
Impedance of venous return
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IPPB
Hazards (AARC)
Exacerbation of hypoxemia Hypoventilation
Increased V/Q mismatch
Air trapping, auto peep, overdistended alveoli
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IPPB
Potential Outcomes
Improved IC or VC Increased FEV1 or peak flow
Enhanced cough or secretion clearance
Improved Chest radiograph
Improved breath sounds
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IPPB
Potential Outcomes
Improved oxygenation Favorable patient subjective response
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IPPB
Baseline Assessment
Vital signs Patients appearance and sensorium
Breathing pattern
Breath sounds
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IPPB
Implementation
Infection control
Equipment preparation Pressure check machine/circuit
Patient orientation Why MD ordered therapy
What treatment does
How it feels
Expected results
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IPPB
Implementation
Application Mouthpiece / nose clip (initially)
Mouthseal
Mask
Trach adaptor
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IPPB
Implementation
Machine settings Sensitivity of 1 2 cm H2O
Initial pressure between 10 15 cm H20
Breathing pattern of 6 breaths/min
I:E ration of 1:3 to 1:4
Flow and pressure will need subsequent
adjustment to patients needs and goal
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IPPB
Implementation
When treating atelectasis Therapy should be volume-oriented
Tidal volumes (VT) must be measured
VT goals must be set
VT goal of 10 15 mL/kg of body weight
Pressure can be increased to reach VT goal if
tolerated by patient
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IPPB
Implementation
When treating atelectasis IPPB is only useful in the treatment of atelectasis
if the volumes delivered exceeds those volumes
achieved by the patients spontaneous efforts
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IPPB
Discontinuation and Follow-Up
Treatments typically last 15-20 minutes Repeat patient assessment
Identify untoward effects
Evaluate progress
Document
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