LUNG EXPANSION THERAPY

Objectives
The focus of this module is on re expanding collapsed alveoli. Collapse of lung tissue makes it more difficult for oxygen to diffuse into the blood. Therefore, reexpanding collapsed lung tissue is a high priority.

The single lesson in this module addresses: The different causes of alveolar collapse and the lung expansion therapies such as incentive spirometry (IS), intermittent positive pressure breathing (IPPB), and continuous positive airway pressure (CPAP) used to reinflate the lungs.

LUNG EXPANSION THERAPY

A group of medical treatment modalities designed to prevent and/or treat pulmonary atelectasis and associated problems

 Atelectasis refers to the collapse of alveoli. Collapse of an entire lobe is called lobar atelectasis. The table describes the three major ways atelectasis occurs. The terms resorption atelectasis, reabsorption atelectasis, and absorption atelectasis all refer to gas being absorbed from the alveolus into the bloodstream. This alveolar collapse occurs: When the alveolus is obstructed More quickly with a higher

Type Resorption atelectasis

Mechanism An obstructed airway = allows gas in the alveoli to be absorbed into the bloodstream Shallow breathing - leads to collapsed alveoli. Space - occupying lesion causes nearby alveoli to collapse

example Blocked airway caused by: Tumor in airway Mucus plug Shallow breathing Postoperative pain from thoracic or upper abdominal surgery Obesity Neuromuscular weakness Sedation Lung compression Pneumothorax Pleural effusion Lung mass

Passive atelectasis

Adhesive atelectasis

Low levels of surfactant

Respiratory distress syndrome (infants)

COMPRESION ATELECTASIS

High risk of atelectasis 55-year-old man who had coronary artery bypass surgery

Low risk of atelectasi 45-year-old man who had knee arthroscopy

Patient with 25 pack-year smoking history and inguinal hernia repair

Healthy 25-year-old with wrist fracture

82-year-old confused woman with a broken hip 15-year-old girl with severe developmental delay and fever

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

 CLINICAL SIGN OF ATELECTASIS

In acute atelectasis in which there is sudden obstruction of the bronchus, there may be dyspnea and cyanosis, elevation of temperature, a drop in blood pressure, or shock. In the chronic form, the patient may experience no symptoms other than gradually developing dyspnea and weakness. X-ray examination may show a shadow in the area of collapse. If an entire lobe is collapsed, the x-ray will show the trachea, heart, and mediastinum deviated toward the collapsed area, with the diaphragm elevated on that side.

 Bronchoscopy may be included in diagnostic procedures to rule out an obstructing neoplasm or a foreign body if the cause is unknown. Other characteristics include diminished breath sounds, fever, and increasing dyspnea (shortness of breath). Diagnosis of Atelectasis Atelectasis is diagnosed by clinical exam, close monitoring of a post-operative clinical course, and x-ray.

PLEURAL EFFUSION

Sustain Maximal Inspiration

Breathing deeply is the easiest way to increase lung volumes

 Increasing the gas flow directly to the alveolus Inflating nearby alveoli through pores of Kohn
A sustained maximal inspiration (SMI) is a deep breath followed by a breath-hold. Patients should also be encouraged to cough and remove any mucus obstructing the airway.

Preparation: Pain control (if appropriate):

Patient should use patient-controlled analgesia (PCA) prior to treatment.

 Hold a pillow over surgical incision (if present) called splinting.

 Position patient to make it easier for diaphragm to descend:

Elevate head of bed (HOB). Dangle feet.

 Teach proper breathing with diaphragm:

Diaphragm contracts and descends. Abdomen should move outward on inspiration:
Coach patient to hold hand over abdomen to monitor movement. Assess bilateral chest wall movement.

Ask patient to inspire maximally:

Use a slow to moderate flow rate:
Decreases pain (if present) Less turbulence in flow pattern

 Hold breath 5 to 10 seconds at the end of inspiration:

Maximizes time for air to inflate collapsed alveoli

Exhale normally.
Repeat 6 to 10 times each hour.

 Lung Expansion Therapy include: a variety of respiratory care modalities designed to increase lung volume Incentive Spirometry - IS therapy IPPB - Intermittent Positive Pressure Breathing PEP Positive Expiratory Pressure EPAP Expiratory positive airway Pressure 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

enhances lung expansion via spontaneous and sustain - is a device that provides the patient with visual feedback. Device that measures the breath volume. A - The goal of IS therapy is to prevent atelectasis if the patient @ high risk of athelectasis - reverse athelectasis if the patient has a symptom of athelectasis

 Incentive spirometry will not be successful if the patient is unconscious or has a vital capacity <10 mL/kg. Patients should be encouraged to pause between each SMI. Breathing too rapidly may cause respiratory alkalosis.

gives a deep breath 2-5 Inflates <5 mL/kg

sleep acidosis

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 Xray reports

At the bedside check for;

mental status; ability to comprehend; pain level; evidence of any pulmonary problems (tachypnea &/or S.O.B.?)

Advantages of I.S. Therapy

Patients can self-administer as often as they like Relatively easy to learn and perform

Commonly use and IS are not appropriate to the pt

Very rare side effects Inexpensive way of preventing pulmonary complications 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

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

Evaluate need for pain medication (if needed). Assess breath sounds and vital signs. Establish treatment goals. Position patient for maximal inspiration. Maximally inhale. Hold breath 5 to 10 seconds. Exhale slowly. Repeat 6 to 10 times. Ask patient to cough. Reassess breath sounds and vital signs. Leave IS within reach of patient. Record treatment in medical record.

Types of I.S. Devices Volume Oriented devices Actually measure & display the amount of air patient inhaled

Types of I.S. Devices Flow Oriented devices

Only display inspiratory flowrate and may attempt to estimate amount of air inhaled

INTERMITTENT POSITIVE PRESSURE BREATHS (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

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 AP-5 series ventilator OR Bird Mark series 7 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

Holder

IPPB Bird Circuit

Exhalation Valve Drive Line Reservoir Tube Mouthpiece

Exhalation Valve

Main Flow Tube

Nebulizer Manifold

inhalation

exhalation

 Electrically Powered Pressure limited

AP- 4

AP - 5
Only patient triggered

IPPB Instruction to the pt Explain 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 they have of you

 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 patients 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 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)

POSITIVE AIRWAY PRESSURE

Positive Pressure creating lung expansion
approaches to positive airway pressure therapy:

(PEP) positive expiratory pressure (EPAP) expiratory positive airway pressure (CPAP) continuous positive airway pressure

INDICATIONS for Positive airway pressure tx

To reduce air trapping in asthma and COPD

To prevent or reverse atelectasis To aid and mobilization or retain secretions To optimize bronchodilator

Potential Contraindication to positve airway pressure tx

Pt unable to tolerate an increased work of breathing Intracranial pressure > 20 mmHg Hemodynamic instability Recent facial, oral, skull surgery or trauma 4 Acute sinusitis Epistaxis Esophageal surgery

Active hemoptysis Nausea Middle air phatology, e.g.,tympanic membrane rupture Untreated pneumothorax

Hazards and complications of positive airway pressure tx Due to increase pressure: Pulmonary barotrauma increased intracranial pressure decreased venous return gastric distention Due to the apparatus Increased work of breathing (resistor) Vomiting/aspiration (gastric distention + mask)

Claustrophobia (mask) Skin break down and discomfort (mask) Epistaxis

PEP Tx (possitive expiratory pressure) a form fitting face mask, a one way T-valve assembly, a p ressure manometer, and an adjustable flow resistor

1. Expiratory resistor (4 settings) 2. One-way valves 3. Manometer 4. Mask 5. Mouthpiece 6. Nebulizer (optional) 7. Aerosol tubing (optional) Picture will be given to hand out

Threshold PEP is used for airway clearance, bronchial hygiene, or as an alternative to chest physical therapy. Threshold PEP incorporates a flow-independent one-way valve to ensure consistent resistance with adjustable specific pressure settings (in cm H20) which are set by the healthcare professional. When patients exhale through Threshold PEP, the resistive load creates positive pressure that helps open the airways and allows mucus to be expelled during "huff" coughing (forced expiratory technique).

The pt should be seated comfortably with elbow resisting on a flat surface The mask is place snugly over the nose and mouth Using diaphragmatic breathing, the pt inhales a volume 2-3 times larger than the normal tidal volume or Vt the slowly exhales not (forcely) to the FRC through the flow resistor, keeping the positive expiratory pressure between 10 and 20 cm H2O and repeated 10-20 breaths, @ which time the mask is removed and the pt. perform 23 huff coughs this sequence repeated 4-6 times for each PEP tx session with intervals 10-20 mins. And vary from twice 4 x daily

EPAP (expiratory positive pressure airway pressure)

Similar to PEP except the treshold resistor replaces the flow resistor The pressure generated by a treshold resistor is independent of flow, usually between 10-20 cm H20. For a person on a ventilator, this would refer to positive airway pressure being provided while they breathe out.

can also be used to describe a device used to treat sleep apnea called Provent. According to the manufacturer, Provent uses a one-way valve that is placed over the nostrils at night time.

EPAP does not require a source of pressurized gas Become positive during inspiration pressure changes in spontaneous and positive pressure breathing

Aproaches to EPAP
The simplest approach is to use the same equipment as use for PEP tx, but replace the flow for resistor this tyope of system requires no pressurized gas A pressurized gas from a flow meter A. Flows continuously into a large volume aerosol generator B. Into the inspiratory limb of the circuit attache to the T-piece in the inspiratory limb of the circuit

C. Is an aerosol reservoil D. Open to the atmosphere this reservoir provides extra volume if the pt inspiratoryflow exceeds that of the system E. Pt breaths in and out through a mask attach to a T- piece F. The expiratory limb of the circuit is connected to a treshold resistor (G) in this case a water column.

 EPAP pressure can be varied by adding or removing water from this column

TRESHOLD RESISTOR FOR CPAP/EPAP

Underwater columns Spring-loaded diaphragms or disks Gravity- weighted balls Balloons valves with preset pressure Reverse venturi systems Electromechanical valves

CLINICAL FINDINGS INDICATING FOR POSSTIVE AIRWAY PRESSURE TX TO TREAT ATELECTASIS

Change in breath sounds consisted with atelectasis Change in vital signs increase in breathing rate tachycardia and fever Abnormal chest x-ray indicating with atelectasis, mucus plugging or infiltrates Deterioration in arterial oxygenation or Spo2

FLUTTER VALVE
The Flutter Valve (Scandipharm products) is a device to deliver PEP therapy in a slightly different approach. The device consists of a mouthpiece connected to a cylinder in which a stainless steel ball rests in a cone shaped valve. The patient exhales through the cylinder and causes the ball to move up and down during the exhalation.

 Purpose: To provide protocol driven respiratory therapy by incorporating the flutter valve to facilitate the mobilization of secretions in patients with chronic high volume sputum production and in patients with an ineffective cough with evidence of retained secretions and/or atelectasis.

 The effect is threefold: first, to vibrate the airways and thus, facilitate movement of mucus; second, to increase endobronchial pressure to avoid air trapping and third, to accelerate expiratory airflow to facilitate the upward movement of mucus.

Policy: 1) Flutter Valve Protocol will be initiated on patients by a written order from the physician. Flutter
Valve may be ordered as: Flutter Valve Therapy RT Protocol RT Consult

Flutter Valve may be used in conjunction with: - Chest Physical Therapy - Autogenic Drainag

 Pulmonary Considerations: Contraindications:

Inability to comprehend instruction or perform breathing maneuvers. Acute dyspnea in which the patient cannot breath hold or control expiratory airflow. Patient with untreated pneumothorax. Immediate post-op nasal, oral, or mouth surgery. Patients less than four years of age, unless they can demonstrate the attention span and

discipline to learn the breathing technique - active hemoptysis right sided heart failure

 Hazards/Complications: Acute Hypotension during procedure Pulmonary Hemorrhage Vomiting and Aspiration Bronchospasm Dysrhythmias Hypoxemi

<pTypes of Patients: Acute Care:

Patients with excessive mucus production having difficulty expectorating and do not have an artificial airway in place.

Subacute /Home Care:

Again, the above statement applies to the home care/subacute setting. Another group of patients that may significantly benefit from Flutter therapy are those with cystic fibrosis. Traditional therapy of postural drainage and chest percussion can take over an hour to complete. Compliance with this therapy becomes difficult, especially with the teenage population. Flutter therapy has been proven to at least equal more traditional forms of therapy in much less time.

 Limitations: The major limitation is patient cooperation and ability to follow directions.

 Assessment of Positive Outcomes: Increased sputum production, patient's subjective response to therapy, improvement in chest xray, ABG's, and/or SaO2.
Tips: The amount of tilt of the Flutter is important. Initally, the mouthpiece should be horizontal to the floor. Then the cone is tilted up or down to achieve maxiaml "flutter" effect. The way this can be assessed is to place your hands on the patient's back and chest. When maximal fluttering is achieved, you will be able to fell the vibrations. The patient may need several sessions to establish the correct tilt.

 In the home care setting, patients should be instructed and monitored on appropriate infection control. After each session, the device should be disassembled, rinsed and dried. Every 2 days, patients should disassemble and clean the device with a mild soap or detergent, rinse, and dry. At regular intervals, the device should be disassembled and soak their cleaned components in a solution of 1 part alcohol to 3 parts tap water for 15 minutes- then rinsed and dried

Vibratory Positive Expiratory Pressure System

BENEFITS
Can accommodate virtually any patients lung capacity. Allows inhalation and exhalation without removing from mouth. May be used with mask or mouthpiece Nebulizer Can accommodate virtually any patient's lung capacity. Reproducible therapies. Use in any position-patient is free to sit, stand or recline

PROCEDURE
1. Ask the patient to slowly inhale beyond a normal breath (but not maximally). (Have the patient hold his/her breath for 2 to 3 seconds. ) 2. Have the patient place the flutter valve in the mouth, keeping cheeks stiff and adjusting the tilt of the cylinder. ( Exhale through the flutter at a fairly fast flow rate, exhaling past normal exhalation (but not maximally).

3. Repeat procedure for 5 to 10 breaths.

 Stage 2 (Eliminating Mucus): 1. Have the patient slowly inhale to a maximal inspiration. 2. Hold breath for 2 to 3 seconds. 3. Place Flutter valve in mouth, adjusting tilt and keeping cheeks stiff. 4. Exhale forcefully through the flutter as completely as possible. 5. Repeat 1 to 2 times. 6. Initiate cough or huff maneuver. 7. Repeat procedure (Stage 1 and 2) until no further mucus production is obtained.

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) A simple approach which maintains some positive pressure in the airway at the end of exhalation Net effect of CPAP is that FRC is increased There is a high correlation between improvement of atelectasis and the patient having a higher than normal FRC

Contraindications to CPAP If blood pressure is very low Diastolic of <50 mm Hg If patient has one or more of the following; Facial trauma (cannot use mask CPAP) Nausea Untreated pneumothorax Elevated intracranial pressure (ICP)

Hazards of the Use of CPAP Barotrauma (pneumothorax) Gastric distension Air-trapping Decrease in BP Can be very uncomfortable to the face of patient using mask CPAP

Beneficial Effects of CPAP Recruitment of collapsed alveoli The work of breathing is decreased as lung compliance (stretchability) improves Improvement of gas distribution Improvement in secretion removal Indications for Use of CPAP Treatment of post-operative atelectasis Should be used continuously Has been used in the treatment of cardiogenic pulmonary edema

CPAP Accomplish? Increases the FRC by increasing the amount of air in the chest at the end of exhalation The net effect of increasing FRC is to; Re-open any atelectatic areas Improve any hypoxemia that may be resulting from the atelectasis CPAP is also used to treat sleep apnea secondary to upper airway obstruction