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LUNG EXPANSION THERAPY
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Objectives
The focus of this module is on re
expanding collapsed alveoli. Collapse
of lung tissue makes it more difficultfor oxygen to diffuse into the blood.
Therefore, reexpanding collapsed
lung tissue is a high priority.
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The single lesson in this module
addresses:The different causes of alveolar
collapse and the lung expansion
therapies such as incentivespirometry(IS), intermittent positive
pressure breathing (IPPB), and
continuous positive airway pressure(CPAP) used to reinflate the lungs.
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LUNG EXPANSION THERAPY
A group of medical treatment
modalities designed to prevent
and/or treat pulmonary atelectasisand associated problems
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Atelectasis refers to the collapse of alveoli.
Collapse of an entire lobe is called lobar
atelectasis.The table describes the threemajor ways atelectasis occurs.
The terms resorption atelectasis,
reabsorption atelectasis, and absorptionatelectasis 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
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Type Mechanism example
Resorption atelectasis An obstructed airway =
allows gas in the alveoli to
be absorbed into the
bloodstream
Blocked airway caused by:
Tumor in airway
Mucus plug
Passive atelectasis Shallow breathing - leads
to collapsed alveoli.
Space - occupying lesion
causes nearby alveoli to
collapse
Shallow breathing
Postoperative pain from
thoracic or upper
abdominal surgery
ObesityNeuromuscular weakness
Sedation
Lung compression
Pneumothorax
Pleural effusionLung mass
Adhesive atelectasis Low levels of surfactant Respiratory distress
syndrome (infants)
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COMPRESION ATELECTASIS
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High risk of atelectasis Low risk of atelectasi
55-year-old man who had coronary
artery bypass surgery
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 severedevelopmental delay and fever
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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 toambulate
Patients with chest trauma or
chest wall injury
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CLINICAL SIGN OF ATELECTASIS In acute atelectasis in which there is sudden
obstruction of the bronchus, there may bedyspnea and cyanosis, elevation oftemperature, a drop in blood pressure, orshock.
In the chronic form, the patient may experienceno symptoms other than gradually developingdyspnea 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, andmediastinum deviated toward the collapsedarea, with the diaphragm elevated on that side.
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Bronchoscopy may be included in diagnostic
procedures to rule out an obstructing
neoplasm or a foreign body if the cause isunknown.
Other characteristics include diminished
breath sounds, fever, and increasing dyspnea(shortness of breath).
Diagnosis of Atelectasis
Atelectasis is diagnosed by clinical exam, closemonitoring of a post-operative clinical course,
and x-ray.
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PLEURAL EFFUSION
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Sustain Maximal Inspiration
Breathing deeply is the easiest way to increase
lung volumes
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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.
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Preparation:
Pain control (if appropriate):
Patient should use patient-controlled analgesia(PCA) prior to treatment.
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Hold a pillow over surgical incision (if present)
called splinting.
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Position patient to make it easier for
diaphragm to descend:
Elevate head of bed (HOB).
Dangle feet.
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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
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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.
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Lung Expansion Therapy include: a variety of
respiratory care modalities designed to
increase lung volume Incentive Spirometry - IS therapy
IPPB - Intermittent Positive Pressure
Breathing
PEPPositive Expiratory Pressure
EPAPExpiratory positive airway Pressure
CPAP - Continuous Positive Airway Pressure
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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
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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
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Incentive spirometry will not be successful if thepatient is unconscious or has a vital capacity
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Prior to Teaching I.S. do the following:
Check the chart for;
Order; Admitting Dx; evidence of any recentsurgery (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.?)
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Advantages of I.S. Therapy
Patients can self-administer as often as they like
Relatively easy to learn and perform
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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
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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
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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.
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Types of I.S. Devices
Volume Oriented devices Actually measure & display the amount of
air patient inhaled
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Types of I.S. Devices
Flow Oriented devices
Only display inspiratory flowrate and may
attempt to estimate amount of air inhaled
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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 thepatients tidal volume (Vt)
How Positive Pressure Ventilation Differs from Normal
In normal breathing, inspiratory pressures arenegative while expiratory pressure are positive
In IPPB, both inspiratory pressures & expiratory
pressure are positive
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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 dueto inability to take a deep breath
Short term ventilatory support when patientis hypercapnic
Enhancement of aerosol medication deliveryin patient unable to take a deep breath
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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
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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!
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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)
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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
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IPPB Bird Circuit
Main Flow Tube
Exhalation Valve
Drive Line
Manifold
Nebulizer
Exhalation
Valve
Holder
Reservoir
Tube
Mouthpiece
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inhalation
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exhalation
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ElectricallyPowered
Pressurelimited
Only patient
triggered
AP- 4
AP - 5
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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
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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 breathingafter the machine cycles (turns on)
Patient will exhale normally in a relaxed way
through the mouth when machine endsinspiration (pre-set pressure is reached)
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What should the therapist emphasize during
the treatment?
Make sure patients keep lips sealed tightaround 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
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Key Aspects & Terms Associated with IPPBventilators
Patient initiates the breath and machine isable to detect the patients effort and thenstarts delivering gas into the mouthpiece
The ability of machine to detect the patientsneed for a breath is called sensitivity
Sensitivity should be set so that machine willbegin breath at a pressure that is 1 or 2
cmH2O pressure below zero (or -1 to -2cmH2O pressure)
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These machines are pressure cycled
This means that inspiration ends when a presetpressure 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 ormask treatments
Pressures less than 15 may be insufficient toincrease the tidal volume (Vt)
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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 deliverany specific volume to the patient
Volume delivered is based upon;
the patients ability to relax and let the machine deliverthe breath
the pressure level set by the therapist the higher the pressure level set - the greater the volume
delivered to the patient (ideally)
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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 f P iti i
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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
P t ti l C t i di ti t it
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Potential Contraindication to positve
airway pressure tx
Pt unable to tolerate an increased work ofbreathing
Intracranial pressure > 20 mmHg
Hemodynamic instabilityRecent facial, oral, skull surgery or trauma 4
Acute sinusitis
EpistaxisEsophageal surgery
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Active hemoptysis
Nausea
Middle air phatology, e.g.,tympanic membrane
rupture
Untreated pneumothorax
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Hazards and complications of positive airwaypressure 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)
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Claustrophobia (mask)
Skin break down and discomfort (mask)
Epistaxis
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PEP Tx (possitive expiratory pressure)
a form fitting face mask, a one way T-valveassembly, a p ressure manometer, and an
adjustable flow resistor
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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
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Threshold PEP is used for
airway clearance,
bronchial hygiene, oras an alternative to chest physical therapy.
Threshold PEP incorporates a flow-independentone-way valve to ensure consistent resistance
with adjustable specific pressure settings(in cm H20) which are set by the healthcareprofessional. When patients exhale throughThreshold PEP, the resistive load creates positive
pressure that helps open the airways and allowsmucus to be expelled during "huff" coughing(forced expiratory technique).
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The pt should be seated comfortably with elbowresisting on a flat surface
The mask is place snugly over the nose and mouthUsing diaphragmatic breathing, the pt inhales a
volume 2-3 times larger than the normal tidalvolume or Vt the slowly exhales not (forcely) to
the FRC through the flow resistor, keeping thepositive expiratory pressure between 10 and 20cm H2O and repeated 10-20 breaths, @ whichtime the mask is removed and the pt. perform 2-
3 huff coughs this sequence repeated 4-6times for each PEP tx session with intervals 10-20mins. And vary from twice 4 x daily
EPAP (expiratory positive pressure
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EPAP (expiratory positive pressure
airway pressure)
Similar to PEP except the treshold resistorreplaces the flow resistor
The pressure generated by a treshold
resistor is independent of flow, usuallybetween 10-20 cm H20.
For a person on a ventilator, this would referto positive airway pressure being providedwhile they breathe out.
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can also be used to describe a device used to
treat sleep apnea called Provent. According to
the manufacturer, Provent uses a one-wayvalve that is placed over the nostrils at night
time.
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EPAP does not require a source of pressurized
gas
Become positive during inspirationpressure changes in spontaneous and
positive pressure breathing
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Aproaches to EPAP
The simplest approach is to use the sameequipment as use for PEP tx, but replace the flowfor resistor
this tyope of system requires no pressurized
gasA pressurized gas from a flow meter
A. Flows continuously into a large volume aerosol
generatorB. Into the inspiratory limb of the circuit attache tothe T-piece in the inspiratory limb of the circuit
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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.
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EPAP pressure can be varied by adding orremoving water from this column
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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
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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
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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 whicha stainless steel ball rests in a cone shaped
valve. The patient exhales through the
cylinder and causes the ball to move up anddown during the exhalation.
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Purpose:
To provide protocol driven respiratory therapyby incorporating the flutter valve to facilitate
the mobilization of secretions in patients with
chronic high volume sputum production andin patients
with an ineffective cough with evidence ofretained secretions and/or atelectasis.
The effect is threefold:
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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 tofacilitate the upward movement of
mucus.
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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:
C i di i
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Contraindications:
Inability to comprehend instruction or performbreathing maneuvers.
Acute dyspnea in which the patient cannot breathhold 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 hemoptysisright sided heart failure
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Hazards/Complications:
Acute Hypotension during procedure
Pulmonary Hemorrhage
Vomiting and Aspiration
Bronchospasm
Dysrhythmias
Hypoxemi
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Acute Care: Patients with excessive mucus production having
difficulty expectorating and do not have an artificialairway 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 therapyare those with cystic fibrosis. Traditional therapy ofpostural drainage and chest percussion can take overan hour to complete. Compliance with this therapybecomes difficult, especially with the teenage
population. Flutter therapy has been proven to atleast equal more traditional forms of therapy inmuch less time.
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Limitations: The major limitation is patient
cooperation and ability to follow directions.
Assessment of Positive Outcomes: Increased
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fsputum production, patient's subjectiveresponse to therapy, improvement in chest x-
ray, ABG's, and/or SaO2. Tips: The amount of tilt of the Flutter is
important. Initally, the mouthpiece should behorizontal to the floor. Then the cone is tilted up
or down to achieve maxiaml "flutter" effect. Theway this can be assessed is to place your handson the patient's back and chest. When maximalfluttering is achieved, you will be able to fell the
vibrations. The patient may need several sessionsto establish the correct tilt.
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In the home care setting, patients should be
instructed and monitored on appropriate
infection control. After each session, thedevice should be disassembled, rinsed and
dried. Every 2 days, patients should
disassemble and clean the device with a mildsoap 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
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Vibratory Positive Expiratory Pressure
System
S
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BENEFITS
Can accommodate virtually any patients lungcapacity.
Allows inhalation and exhalation withoutremoving from mouth.
May be used with mask or mouthpiece Nebulizer
Can accommodate virtually any patient's lungcapacity. Reproducible therapies.
Use in any position-patient is free to sit, stand orrecline
PROCEDURE
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PROCEDURE
1. Ask the patient to slowly inhale beyond anormal breath (but not maximally).(Have the patient hold his/her breath for 2 to 3seconds. )
2. Have the patient place the flutter valve in themouth, keeping cheeks stiff and adjusting thetilt of the cylinder.
( Exhale through the flutter at a fairly fast flowrate, exhaling past normal exhalation (but notmaximally).
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3. Repeat procedure for 5 to 10 breaths.
Stage 2 (Eliminating Mucus):
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1. Have the patient slowly inhale to a maximalinspiration.
2. Hold breath for 2 to 3 seconds.
3. Place Flutter valve in mouth, adjusting tilt andkeeping cheeks stiff.
4. Exhale forcefully through the flutter ascompletely as possible.
5. Repeat 1 to 2 times.
6. Initiate cough or huff maneuver.
7. Repeat procedure (Stage 1 and 2) until nofurther mucus production is obtained.
lCONTINUOUS POSITIVE AIRWAY PRESSURE
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CONTINUOUS POSITIVE AIRWAY PRESSURE
(CPAP)
A simple approach which maintains somepositive 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
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If blood pressure is very low
Diastolic of
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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
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Beneficial Effects of CPAP
Recruitment of collapsed alveoli
The work of breathing is decreased as lungcompliance (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 cardiogenicpulmonary edema
CPAP Accomplish?
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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