Lung Expansion Therapy

Part 1

By Jim Clarke
 What is Lung Expansion Therapy?

• A group of medical treatment modalities

designed to prevent and/or treat pulmonary
atelectasis and associated problems
 Causes & Types of Atelectasis
• Resorption atelectasis
– a blockage occurs in the airway- preventing ventilation
downstream - resulting in eventual removal of
remaining gas & alveolar collapse
• Passive atelectasis-
– Occurs when patients do not take periodic deep breaths
(sighs)
• Compressive atelectasis
– Occurs when something outside the lung presses on
lung tissue causing it to collapse
 What Patients Are “at-risk” for
Atelectasis
• Post-op thoracic or abdominal surgery
patients
• Any heavily sedated patient
• Patients who have neuromuscular diseases
– These diseases may weaken breathing muscles
• Patients who are unable to ambulate
• Patients with chest trauma or chest wall
injury
 How do we know if someone has
an Atelectasis?

• “Gold Standard” - evidence of atelectasis

on a chest x-ray (CXR)
Example of Upper Lobe
Atelectasis
 Methods Used for Lung
Expansion Therapy

• Incentive Spirometry - IS therapy

• IPPB - Intermittent Positive Pressure
Breathing
• CPAP - Continuous Positive Airway
Pressure
 Incentive Spirometry

• Used primarily as a preventative or

prophylactic treatment
• Patient are encouraged to take slow - deep
inspirations ten times every hour
• Patients are taught to perform 5-10 second
breath holds at maximal inhalation for each
of the 10 hourly breaths
 Advantages of I.S. Therapy

• Patients can self-administer as often as they

like
• Relatively easy to learn and perform
• Very rare side effects
• Inexpensive way of preventing pulmonary
complications
 Reasons Why I.S. May Not Be
Appropriate

• Patient is not alert or cannot follow

instructions
• Patient cannot hold mouthpiece in their
mouth
• Patient has a large atelectasis that must be
treated with more aggressive measures
• Patient cannot create a large enough breath
for I.S. to be of any real value
 Prior to Teaching I.S. do the
following:
• Check the chart for;
– Order; Admitting Dx; evidence of any recent
surgery (when?; type?); evidence of any
previous pulmonary problems (COPD;
asthma?); Chest X-ray reports
• At the bedside check for;
– mental status; ability to comprehend; pain
level; evidence of any pulmonary problems
(tachypnea &/or S.O.B.?)
 What to Focus on During I.S.
Instruction

• What is I.S.
• Why is the patient going to learn how to
perform it
• How often should the patient perform it
• Does the patient have any questions
 Types of I.S. Devices

• Volume Oriented devices

– Actually measure & display the amount of air
patient inhaled
• Flow Oriented devices
– Only display inspiratory flowrate and may
attempt to estimate amount of air inhaled
Examples of Two Electronic I.S.
Devices
 Example of a Flow-Oriented
Device
 IPPB as Method of Enhancing
Lung Expansion

• Definition - Lung expansion therapy

utilizing positive airway pressure for
periods of 15 - 25 minutes to enhance
resting lung ventilation by increasing the
patients tidal volume (Vt)
 How Positive Pressure
Ventilation Differs from Normal

• In normal breathing, inspiratory pressures

are negative while expiratory pressure are
positive
• In IPPB, both inspiratory pressures &
expiratory pressure are positive
How Pressures Change During
Inspiration
 Indications For IPPB
• Patient has an atelectasis that is not responding to
I.S. therapy
• Patient cannot perform I.S. therapy
– This may also be a problem with IPPB!!
• Poor cough effort & secretion clearance due to
inability to take a deep breath
• Short term ventilatory support when patient is
hypercapnic
• Enhancement of aerosol medication delivery in
patient unable to take a deep breath
 Contraindications to IPPB

• Untreated pneumothorax
• High intracranial pressure (>15 mm Hg)
• Active hemoptysis
• Radiographic evidence of a bleb
• Nausea
• Tracheo-esophagel fistula
• Recent esophageal surgery
Hazards & Complications of IPPB

• Barotrauma (pneumothorax)
• Hyperventilation (dizziness)
• Gastric distension (secondary to air swallowing)
• Decrease in venous return (possible drop in
B.P.)
• Increased airway resistance
– May actually cause bronchospasm in some patients!
 Monitoring the IPPB Treatment
• What is the pulse & respiratory rate prior to
treatment?
• What are the patients breath sounds; their
color; respiratory effort; mental state - prior
to the Tx?
• What is the patients SpO2 or peakflow
before the treatment (if giving bronchodilators)
 Equipment Needed for IPPB
• IPPB Ventilator -
– Bennett “PR series” ventilator OR Bird “Mark
series” ventilator
• IPPB tubing circuit
– “Universal” disposable circuits now used
• Additional equipment “possibly” needed;
– Mouthseal & noseclips for patients who cannot
use mouthpiece
– Mask (if mouthseal is not available)
– Connector for using circuit with trach patient
Key Elements of IPPB Instruction

• What is IPPB
• Why is the patient going to be receiving
IPPB treatments
• How long is each treatment & how often
will they receive it
• What should they do during the treatment
• Any questions
 What should the patient do
during IPPB?
• Patient starts their breath; the machine
cycles on
• Patient relaxes and lets the machine fill
their lungs
– Patient should NOT be actively breathing
after the machine cycles (turns on)
• Patient will exhale normally in a relaxed
way through the mouth when machine ends
inspiration (pre-set pressure is reached)
 What should the therapist
emphasize during the treatment?

• Make sure patients keep lips sealed tight

around the mouthpiece
• Coach patient to not actively breath
– “Relax and let the machine fill your lungs!”
• Make sure patient does not breath too
rapidly during treatment
– This will cause dizziness secondary to
hyperventilation
 Key Aspects & Terms Associated
with IPPB ventilators

• Patient initiates the breath and machine is

able to detect the patient’s effort and then
starts delivering gas into the mouthpiece
– The ability of machine to detect the patients
need for a breath is called “sensitivity”
– Sensitivity should be set so that machine will
begin breath at a pressure that is 1 or 2 cmH2O
pressure below zero (or -1 to -2 cmH2O
pressure)
 These machines are “pressure
cycled”

– This means that inspiration ends when a preset

pressure is reached in the circuit
– Preset pressure is set by the therapist
• Typical pressure ranges (15 - 25 cmH2O)
• Pressures higher than 25 associated with “air
swallowing” particularly with mouthseal or mask
treatments
• Pressures less than 15 may be insufficient to
increase the tidal volume (Vt)
 Characteristics of Pressure
Cycling
• Any leak in the “circuit” or in the patient
will cause the machine to not end
inspiration (cycle off)
• Patient can easily end the breath by
– blowing back into the mouthpiece
– putting their tongue over the mouthpiece
• Pressure cycled machine can NOT
guaranteed to deliver any specific volume
to the patient
 Characteristics of Pressure
Cycling

• Volume delivered is based upon;

• the patients ability to relax and let the
machine deliver the breath
• the pressure level set by the therapist
– the higher the pressure level set - the greater the
volume delivered to the patient (ideally)
End of Week 2 - Thursday