Volume Expansion Therapy (VET)

RET 2275

Respiratory Care Theory 2

Volume Expansion Therapy (VET)

Volume Expansion Therapy AKA

Lung expansion therapy Hyperinflation therapy

A variety or respiratory care modalities designed to prevent or correct atelectasis by augmenting lung volumes

Incentive Spirometry (IS) Intermittent Positive Airway Pressure (IPPB) Continuous Positive Airway Pressure (CPAP) Positive Expiratory Pressure (PEP)

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

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 is impaired or lost

Volume Expansion Therapy (VET)

The Sigh Mechanism Factors that can impair the sigh mechanism

General anesthesia Pain Pain medication Decreased level of consciousness Thoracic or upper abdominal surgery Impaired diaphragmatic movement

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 negative alveolar & pleural pressures reexpand collapsed alveoli and prevent the collapse of ventilated alveoli

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 with quadriplegia and/or dysfunctional diaphragm

Volume Expansion Therapy (VET)

Contraindications for VET

Inability of patient to be instructed to perform SMI maneuver

Lack of patient cooperation

Inability of patient to deep breathe (i.e. VC <10 ml/kg)

Volume Expansion Therapy (VET)

Hazards & Complications of VET

Ineffective in absence of correct technique (may require repeated instruction & coaching)

Hyperventilation

Exacerbation of bronchospasm

Volume Expansion Therapy (VET)

Hazards & Complications of VET

Hypoxemia (if O2 therapy is interrupted)

Barotrauma (in emphysematous lungs)

Fatigue

Pain in postoperative patients

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 the respiratory muscles

Volume Expansion Therapy (VET)

Findings Consistent with Atelectasis

Diminished breath sounds & fine crackles in affected area

Fever

Tachypnea & tachycardia

Dull percussion note

Characteristic opacity on chest x-ray

Volume Expansion Therapy (VET)

Incentive Spirometry Equipment

Device is only a visual aid

Importance is placed on patient performing the correct maneuver

Volume Expansion Therapy (VET)

Incentive Spirometry (IS) Equipment

Volume IS

Volume Expansion Therapy (VET)

Incentive Spirometry (IS) Equipment

Flow oriented (flow x time = volume)

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

patient’s understanding and cooperation Position patient

Sitting or semi-Fowler’s

Semi-Fowler’s Position (Head elevated 30)

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 normal exhalation

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 is

required

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

Volume Expansion Therapy (VET)

Assessment of Outcome

Normal chest x-ray

Improved oxygenation (PaO2/SpO2)

Return of normal spirometric values

Improved respiratory muscle performance

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

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, some fine 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 Patient Education 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 StudentRespiratory Care

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 patient’s reach

Provide rest periods as necessary

CPAP

Definition The application of a

positive airway pressure to the spontaneously breathing patient throughout the respiratory cycle at pressures of 5 – 20 cm H2O

CPAP

Physiological Principles CPAP elevates and maintains high alveolar and

airway pressures throughout the full breathing cycle.

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

CPAP

Physiologic Principles - Equipment

CPAP

Physiologic Principles CPAP

Recruits collapsed alveoli via an increase in FRC

CPAP

Physiologic Principles CPAP

Recruits collapsed alveoli via an increase in FRC Decreases work of breathing due to increased compliance

or abolition of auto-PEEP Improves distribution of ventilation through collateral

channels (e.g., Kohn’s pores) Increases the efficiency of secretion removal

CPAP

Indications Postoperative atelectasis

Cardiogenic pulmonary edema Refractory hypoxemia

PaO2 <60 mm Hg, SaO2 <90% on an FiO2 >0.40 – 0.50 in the presence of adequate ventilatory status (PaCO2 <45 mm Hg, pH 7.35 – 7.45)

Obstructive sleep apnea

CPAP

Contraindications Hemodynamic instability Hypoventilation

CPAP does not ensure ventilation Nausea Facial trauma Untreated pneumothorax Elevated intracranial pressure

CPAP

Hazards and Complications Increased work of breathing caused by the apparatus

Hypoventilation and hypercapnia Patients with ventilatory insufficiency may

hypoventilate 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

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 patient’s need

Flow initially set to 2 – 3 times the patients minute ventilation

Flow is adequate when the system pressure drops no more than 1 – 2 cm H2O during inspiration

CPAP

Patient Interfaces

Nasal Mask

CPAP

Patient Interfaces

Fitting the Nasal Mask Dorsum of nasal bridge Around the nasal alae Mid philtrum Use foam bridge

Prevents collapse of mask

onto nose

CPAP

Patient Interfaces

Fitting the Nasal Mask DO NOT over tighten

Tissue necrosis

CPAP – Tissue necrosis

CPAP

Patient Interfaces

Full-Face Mask

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

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

CPAP

Patient Interfaces

Total Face Mask

EZ-PAP

Lung expansion therapy during inspiration and PEP therapy during exhalation

Used for the treatment or prevention of atelectasis and the mobilization of secretions

Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator

EZ-PAP

EZ-PAP

EZ-PAP

EZ-PAP with SVN

IPPB

Definition

The application of inspiratory positive pressure to a spontaneously breathing patient as an intermittent or short-term therapeutic modality

IPPB

Definition

The delivery of a slow deep sustained inspiration by a mechanical device providing controlled positive pressure breath during inspiration

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

IPPB

Indications (AARC)

Short-term nonivasive ventilatory support for hypercapnic patients Alternative to intubation and continuous

ventilatory support

IPPB

Indications (AARC)

The need to deliver aerosol medication When MDI or nebulizer has been unsuccessful Patients with ventilatory muscle weakness or

fatigue

IPPB

Contraindications (AARC)

Tension pneumothorax

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ICP > 15 mm Hg Hemodynamic instability Recent facial, oral or skull surgery

IPPB

Contraindications (AARC)

Tracheoesophageal fistula Recent esophageal surgery Active hemoptysis Nausea Air swallowing

IPPB

Contraindications (AARC)

Active, untreated TB Radiographic evidence of bleb Singulus (hiccups)

IPPB

Hazards (AARC)

Increase airway resistance (Raw) Barotrauma, pneumothorax Nosocomial infection Hyperventilation (hypocapnia) Hemoptysis

IPPB

Hazards (AARC)

Hyperoxia when O2 is the gas source Gastric distention Secretion impaction (inadequate humidity) Psychological dependence Impedance of venous return

IPPB

Hazards (AARC)

Exacerbation of hypoxemia Hypoventilation Increased V/Q mismatch Air trapping, auto peep, overdistended alveoli

IPPB

Potential Outcomes

Improved IC or VC Increased FEV1 or peak flow Enhanced cough or secretion clearance Improved Chest radiograph Improved breath sounds

IPPB

Potential Outcomes

Improved oxygenation Favorable patient subjective response

IPPB

Baseline Assessment

Vital signs Patient’s appearance and sensorium Breathing pattern Breath sounds

IPPB

Implementation

Infection control Equipment preparation

Pressure check machine/circuit Patient orientation

Why MD ordered therapy What treatment does How it feels Expected results

IPPB

Implementation

Application Mouthpiece / nose clip (initially) Mouthseal Mask Trach adaptor

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 patient’s needs and goal

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

IPPB

Implementation

When treating atelectasis IPPB is only useful in the treatment of atelectasis

if the volumes delivered exceeds those volumes achieved by the patient’s spontaneous efforts

IPPB

Discontinuation and Follow-Up

Treatments typically last 15-20 minutes Repeat patient assessment Identify untoward effects Evaluate progress Document