1. RT 210 Lung Expansion / Hyperinflation TX RT 210 Hyperinflation TX

2. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS Indications Indications To improve atelectasis To improve atelectasis To prevent atelectasis To prevent atelectasis Post ‑ op Post ‑ op COPD COPD Other pulmonary complications Other pulmonary complications Mobilize secretions Mobilize secretions RT 210 Hyperinflation TX

3. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS Contraindications Contraindications Patient unable to cooperate Patient unable to cooperate Patient unable to follow instructions Patient unable to follow instructions Patient unconscious Patient unconscious Patient unable to take deep breaths Patient unable to take deep breaths RT 210 Hyperinflation TX

4. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS Hazards Hazards Ineffective unless performed correctly Ineffective unless performed correctly Hyperventilation Hyperventilation Barotrauma Barotrauma Discomfort secondary to pain Discomfort secondary to pain Fatigue Fatigue RT 210 Hyperinflation TX

5. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS Procedure Procedure Slow deep inspiration Slow deep inspiration Inspiratory hold Inspiratory hold Relaxed exhalation Relaxed exhalation Volume of gas moved should be inspiratory capacity Volume of gas moved should be inspiratory capacity Maximum inhalation following a quiet exhalation Maximum inhalation following a quiet exhalation RT 210 Hyperinflation TX

6. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS Procedure (cont) Procedure (cont) Coaching the patient is important Coaching the patient is important Encouragement Encouragement Insure proper technique Insure proper technique Frequency Frequency May be performed by patient after instruction May be performed by patient after instruction Q 1 hour while awake Q 1 hour while awake Follow ‑ up daily or PRN Follow ‑ up daily or PRN RT 210 Hyperinflation TX

7. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS Equipment Equipment Most actually measure flow and time Most actually measure flow and time Triflow Triflow InspiRx InspiRx Some measure volume Some measure volume Bartlett Edwards (Bellows) Bartlett Edwards (Bellows) Inspiron (Vortex Principle) Inspiron (Vortex Principle) RT 210 Hyperinflation TX

8. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS Patient Evaluation Patient Evaluation Alert Alert Cooperative Cooperative Physically able to increase IC greater than VT Physically able to increase IC greater than VT Should be 3 times predicted VT Should be 3 times predicted VT RT 210 Hyperinflation TX

13. IPPB Intermitent Positive Pressure Breathing RT 210 Hyperinflation TX

14. IPPB Indications Primary Primary If patient has inadequate VC to facilitate a cough, VC less than 3 times predicted VT then VC less than 15ml/kg of ideal body weight If patient has inadequate VC to facilitate a cough, VC less than 3 times predicted VT then VC less than 15ml/kg of ideal body weight RT 210 Hyperinflation TX

15. IPPB Indications Secondary Secondary To deliver medication To deliver medication Improve I:E ratio Improve I:E ratio Improve cough and mobilize secretions Improve cough and mobilize secretions Alter V/Q Alter V/Q To improve or prevent atelectasis To improve or prevent atelectasis To decrease CO2 temporarily To decrease CO2 temporarily RT 210 Hyperinflation TX

16. Contraindications of IPPB Absolute Absolute An untreated closed pneumothorax An untreated closed pneumothorax RT 210 Hyperinflation TX

17. Contraindications of IPPB Secondary Contraindications Secondary Contraindications ICP > 15mmHg ICP > 15mmHg Hemodynamic instability Hemodynamic instability Recent facial, oral, or skull surgery Recent facial, oral, or skull surgery Tracheal-esophageal fistula Tracheal-esophageal fistula Active hemoptysis Active hemoptysis Active TB Active TB Blebs or bullae Blebs or bullae RT 210 Hyperinflation TX

18. Contraindications of IPPB Hazards/Complications Hazards/Complications Barotrauma - pneumothorax Barotrauma - pneumothorax Nosocomial infection Nosocomial infection Hypocarbia Hypocarbia Hyperoxia Hyperoxia Tachypnea Tachypnea Gastric distension Gastric distension Impedance of venous return Impedance of venous return Air trapping Air trapping RT 210 Hyperinflation TX

19. Contraindications of IPPB Hazards/Complications (cont) Hazards/Complications (cont) Increased ICP Increased ICP O2 induced hypoventilation in COPD patients O2 induced hypoventilation in COPD patients Decreased cardiac output Decreased cardiac output May cause or worsen hemoptysis May cause or worsen hemoptysis RT 210 Hyperinflation TX

20. Contraindications of IPPB Hazards/Complications (cont) Hazards/Complications (cont) Hyperventilation Hyperventilation Dizziness Dizziness Loss of consciousness Loss of consciousness Tetany Tetany Paresthesia: Decreased cerebrovascular PCO2 during hyperventilation causes vasoconstriction and decreased cerebral blood flow Paresthesia: Decreased cerebrovascular PCO2 during hyperventilation causes vasoconstriction and decreased cerebral blood flow RT 210 Hyperinflation TX

21. Physiologic Effects of IPPB Increased intrapulmonary pressure Increased intrapulmonary pressure Decreased venous return, worsened by increasing inspiratory time Decreased venous return, worsened by increasing inspiratory time May decrease cardiac output May decrease cardiac output Mechanical bronchodilation Mechanical bronchodilation Altered I:E ratio Altered I:E ratio RT 210 Hyperinflation TX

22. Physiologic Effects of IPPB Altered V/Q ratio Altered V/Q ratio Mobilization of secretions Mobilization of secretions Generally increased PaO2 and decreased PaCO2 Generally increased PaO2 and decreased PaCO2 Decreased work of breathing Decreased work of breathing RT 210 Hyperinflation TX

23. Administration of IPPB Demonstrate set ‑ up Demonstrate set ‑ up Check for leaks Check for leaks Patient instruction Patient instruction Passive treatment Passive treatment Slow deep inspiration with hold Slow deep inspiration with hold Maintain seal Maintain seal Explain nature of and expected results of Rx Explain nature of and expected results of Rx Rx should be gentle start to inhalation, with slow, deep breath, followed by passive exhalation Rx should be gentle start to inhalation, with slow, deep breath, followed by passive exhalation RT 210 Hyperinflation TX

24. Administration of IPPB Coaching patient Coaching patient Calm and reassure patient/relaxation Calm and reassure patient/relaxation Verbally instruct in timing of inspiration and expiration Verbally instruct in timing of inspiration and expiration Total relaxed exhalation Total relaxed exhalation RT 210 Hyperinflation TX

25. Administration of IPPB Monitoring patient Monitoring patient Breath sounds Breath sounds VT (3 times predicted VT) VT (3 times predicted VT) Respiratory rate Respiratory rate Pulse: Stop Rx when increased by 20 BPM Pulse: Stop Rx when increased by 20 BPM Verbal response Verbal response Ask subjective responses Ask subjective responses Dizziness Dizziness Tingling Tingling RT 210 Hyperinflation TX

26. PAP Define & Physiologic Principles Define & Physiologic Principles Indications Indications Contraindications Contraindications Hazards & complications of CPAP (Egan mini clinic) Hazards & complications of CPAP (Egan mini clinic) Equipment Equipment Administer Intermittent CPAP Administer Intermittent CPAP Monitoring and Troubleshooting Monitoring and Troubleshooting RT 210 Hyperinflation TX

27. Bird Mark 7 & 8 (10 & 14) Classification Classification Positive pressure ventilator forces air into lungs Positive pressure ventilator forces air into lungs Pneumatically powered doesn't require electricity (gas powered) Pneumatically powered doesn't require electricity (gas powered) Pneumatically driven Pneumatically driven It's regulator is like a gauge regulators It's regulator is like a gauge regulators Pneumatically driven ceramic switch Pneumatically driven ceramic switch Single circuited: the same gas supply goes to the patient that powers the machine Single circuited: the same gas supply goes to the patient that powers the machine RT 210 Hyperinflation TX

28. Bird Mark 7 & 8 (10 & 14) Modes Modes Assist Assist The only mode used for IPPB The only mode used for IPPB Patient sets rate, then machine delivers rate Patient sets rate, then machine delivers rate Assist Control Assist Control Used for continuous ventilation Used for continuous ventilation If patient fails to set rate, machine will deliver preset rate If patient fails to set rate, machine will deliver preset rate Control: machine set rate and does not allow patient to alter preset pattern Control: machine set rate and does not allow patient to alter preset pattern RT 210 Hyperinflation TX

29. Bird Mark 7 & 8 (10 & 14) Pressure cycled Pressure cycled Cycling is what ends inspiration Cycling is what ends inspiration When set pressure is reached, machine ends inspiration When set pressure is reached, machine ends inspiration Other possibilities of cycling Other possibilities of cycling Flow Flow Time Time Volume Volume Flow limit - can be set Flow limit - can be set RT 210 Hyperinflation TX

30. Bird Mark 7 & 8 (10 & 14) Flow pattern Flow pattern Determined by 100% or air mix setting due to effects of back pressure on the Venturi gate Determined by 100% or air mix setting due to effects of back pressure on the Venturi gate 100% ‑ square wave, flow remains constant in the face of back pressure - "flow generator" 100% ‑ square wave, flow remains constant in the face of back pressure - "flow generator" Air mix ‑ decaying flow curve due to partial closure of Venturi gate Air mix ‑ decaying flow curve due to partial closure of Venturi gate Due to back pressure, flow decreases as pressure increases Due to back pressure, flow decreases as pressure increases RT 210 Hyperinflation TX

31. Bird Mark 7 & 8 (10 & 14) Pressure pattern Pressure pattern Determined by flow pattern Determined by flow pattern 100% source gas rectilinear 100% source gas rectilinear Air mix parabolic Air mix parabolic RT 210 Hyperinflation TX

32. Bird Mark 7 & 8 (10 & 14) Internal resistance Internal resistance How the flow curve is effected by back pressure How the flow curve is effected by back pressure Air mix – low Air mix – low flow pattern is much effected by back pressure flow pattern is much effected by back pressure RT 210 Hyperinflation TX

33. Bird Mark 7 & 8 (10 & 14) Principles of Operation Principles of Operation Magnetism versus gas pressure Magnetism versus gas pressure Two chambers of machine divided by a diaphragm Two chambers of machine divided by a diaphragm Left side: same as atmospheric pressure Left side: same as atmospheric pressure Right side - same as system pressure Right side - same as system pressure RT 210 Hyperinflation TX

34. Bird Mark 7 & 8 (10 & 14) On inspiration, diaphragm is drawn to the right by decreased system pressure when patient initiates a breath On inspiration, diaphragm is drawn to the right by decreased system pressure when patient initiates a breath As pressure builds up on pressure side, the diaphragm is pushed back to the left over ‑ coming pressure of the magnetic pull of the switch plate As pressure builds up on pressure side, the diaphragm is pushed back to the left over ‑ coming pressure of the magnetic pull of the switch plate A ceramic switch is moved by diaphragm which turns gas flow on and off A ceramic switch is moved by diaphragm which turns gas flow on and off RT 210 Hyperinflation TX

35. Bird Mark 7 & 8 (10 & 14) Specifications Specifications Flow is variable and adjustable Flow is variable and adjustable Peak flows on 100% 0 ‑ 50 LPM Peak flows on 100% 0 ‑ 50 LPM Peak flow on air mix 0 ‑ 80 LPM Peak flow on air mix 0 ‑ 80 LPM Venturi gate Venturi gate Open -2 cm H2O Open -2 cm H2O Closes at 2cms H2O lower (Venturi gate spring resistance) then peak or set pressure Closes at 2cms H2O lower (Venturi gate spring resistance) then peak or set pressure RT 210 Hyperinflation TX

36. Bird Mark 7 & 8 (10 & 14) Air Mix controller Air Mix controller Determines 100% source gas or air mix Determines 100% source gas or air mix Air mix Air mix If O2 is the source gas, FIO2 will be 0.4 to 0.8 If O2 is the source gas, FIO2 will be 0.4 to 0.8 The machine functions as a pressure generator The machine functions as a pressure generator 100% 100% FIO2 will be FIO2 of source gas FIO2 will be FIO2 of source gas The machine functions as a flow generator The machine functions as a flow generator RT 210 Hyperinflation TX

37. Bird Mark 7 & 8 (10 & 14) Nebulizer drive Nebulizer drive Nonadjustable Nonadjustable FIO2 will be FIO2 of source gas FIO2 will be FIO2 of source gas Breaks off gas flow before Venturi Breaks off gas flow before Venturi Pressure Pressure Located on right side of ventilator Located on right side of ventilator Adjustable 0 ‑ 60 cmH2O (Mark ‑ 7, 8, 10) Adjustable 0 ‑ 60 cmH2O (Mark ‑ 7, 8, 10) In mmHg Mark ‑ 14 In mmHg Mark ‑ 14 The closer the magnet to the clutch plate the higher the pressure required to cycle The closer the magnet to the clutch plate the higher the pressure required to cycle RT 210 Hyperinflation TX

38. Bird Mark 7 & 8 (10 & 14) Sensitivity Sensitivity Adjustable on ambient (left) side of machine Adjustable on ambient (left) side of machine The closer the clutch plate to the magnet, the less sensitive or more pressure required to initiate inspiration The closer the clutch plate to the magnet, the less sensitive or more pressure required to initiate inspiration Apnea Timer Apnea Timer Works off of a small leak altering pressure internally Works off of a small leak altering pressure internally Allows machine to be used for A/C or control modes Allows machine to be used for A/C or control modes Not used for routine IPPB Not used for routine IPPB RT 210 Hyperinflation TX

39. Bird Mark 7 & 8 (10 & 14) Bird Mark 8 Bird Mark 8 Has negative expiratory pressure capabilities Has negative expiratory pressure capabilities Used Q circuit set ‑ up Used Q circuit set ‑ up Not normally used for IPPB Not normally used for IPPB RT 210 Hyperinflation TX

40. Bird Mark 7 & 8 (10 & 14) Bird Mark 10 Bird Mark 10 Has flow accelerator Has flow accelerator Increases flow at end inspiration to compensate for leaks Increases flow at end inspiration to compensate for leaks RT 210 Hyperinflation TX

41. Bird Mark 7 & 8 (10 & 14) Bird Mark 14 Bird Mark 14 Has higher pressure capabilities, flow accelerator Has higher pressure capabilities, flow accelerator No negative pressure No negative pressure RT 210 Hyperinflation TX

42. Bird Mark 7 & 8 (10 & 14) Circuit Circuit Large bore tubing Large bore tubing Side stream or mainstream Side stream or mainstream Exhalation valve Exhalation valve One small bore tubing with "Y" to allow delivery to exhalation valve and nebulizer One small bore tubing with "Y" to allow delivery to exhalation valve and nebulizer Mouthpiece, mask or trachea adaptor Mouthpiece, mask or trachea adaptor RT 210 Hyperinflation TX

43. Bennett Ventilators Classification Positive pressure Positive pressure Pneumatically powered Pneumatically powered AP series is electrical AP series is electrical Pneumatically driven Bennett Valve Pneumatically driven Bennett Valve Single circuited Single circuited Modes Modes Assist: only for IPPB Assist: only for IPPB Assist/Control: not for IPPB treatments Assist/Control: not for IPPB treatments RT 210 Hyperinflation TX

44. Bennett Ventilators Classification Flow cycled Flow cycled Pressure causes flow to drop to 1 ‑ 3 LPM and ends inspiration Pressure causes flow to drop to 1 ‑ 3 LPM and ends inspiration PR ‑ 2 can be time cycled PR ‑ 2 can be time cycled Pressure limited: Preset control pressure Pressure limited: Preset control pressure Decaying flow pattern Decaying flow pattern Parabolic pressure pattern Parabolic pressure pattern Low internal resistance: back pressure greatly influences flow pattern Low internal resistance: back pressure greatly influences flow pattern RT 210 Hyperinflation TX

45. Bennett Ventilators Classification Method of Operation Bennett valve ‑ a counter balanced drum with vanes and windows allowing rotation to permit flow through the windows or to stop it Bennett valve ‑ a counter balanced drum with vanes and windows allowing rotation to permit flow through the windows or to stop it Sensitivity Sensitivity Adjustment to regulate patient effort Adjustment to regulate patient effort Set as sensitive as possible to insure minimal patient effort Set as sensitive as possible to insure minimal patient effort Less than ‑ 2cm H2O for assist mode Less than ‑ 2cm H2O for assist mode Nebulization Nebulization Is off air dilution Is off air dilution May be continuous or intermittent May be continuous or intermittent Adjustable Adjustable RT 210 Hyperinflation TX

46. Bennett Ventilators Classification Method of Operation Circuit setup Circuit setup Large bore tubing Large bore tubing Nebulizer Nebulizer Adaptor to patient Adaptor to patient Expiratory valve Expiratory valve 2 small bore tubes ‑ one for expiratory valve and other for nebulization 2 small bore tubes ‑ one for expiratory valve and other for nebulization RT 210 Hyperinflation TX

47. Description of Bennett Models AP ‑ 4 & 5 AP ‑ 4 & 5 Electrically powered Electrically powered Compressor driven Compressor driven Flow sensitive Flow sensitive Flow cycled (1 ‑ 2 LPM) Flow cycled (1 ‑ 2 LPM) Single circuit Single circuit Assistor only Assistor only Pressure limited Pressure limited Low internal resistance Low internal resistance Decaying flow pattern Decaying flow pattern Parabolic pressure pattern Parabolic pressure pattern RT 210 Hyperinflation TX

48. Description of Bennett Models Venturi models ‑ PR ‑ 1, PR ‑ 2 Venturi models ‑ PR ‑ 1, PR ‑ 2 Knob in ‑ room air entrained Knob in ‑ room air entrained Knob out ‑ 100% source gas Knob out ‑ 100% source gas Flow/Pres. characteristics same for both setting Flow/Pres. characteristics same for both setting Air mix delivers FIO2 above 0.40 Air mix delivers FIO2 above 0.40 RT 210 Hyperinflation TX

49. Description of Bennett Models PR ‑ 1 PR ‑ 1 No Adjustment of peak flow No Adjustment of peak flow No negative pressure No negative pressure No terminal flow (like flow accelerator on Bird) to compensate for leaks No terminal flow (like flow accelerator on Bird) to compensate for leaks RT 210 Hyperinflation TX

50. Description of Bennett Models PR ‑ 2 PR ‑ 2 Has terminal flow Has terminal flow Peak flow decelerator Peak flow decelerator Negative pressure Negative pressure RT 210 Hyperinflation TX

51. Description of Bennett Models AP Series AP Series Same Bennett valve Same Bennett valve Electrically compressor driven Electrically compressor driven Used for home care frequently Used for home care frequently RT 210 Hyperinflation TX

52. General Considerations For IPPB Therapeutic Units Increasing pressure will increase volume delivered and I:E ratio Increasing pressure will increase volume delivered and I:E ratio Increasing flow rate will decrease inspiratory time and decrease I:E ratio Increasing flow rate will decrease inspiratory time and decrease I:E ratio Increasing sensitivity is desirable unless autocycle occurs Increasing sensitivity is desirable unless autocycle occurs Rate control is not used during IPPB (pure assist mode) Rate control is not used during IPPB (pure assist mode) RT 210 Hyperinflation TX

54. General Considerations For IPPB Therapeutic Units Nebulizer should be adjusted to create optimum aerosol production without wasting medication Nebulizer should be adjusted to create optimum aerosol production without wasting medication Initial volume/pressure relationship is based upon normal compliance value, and adjusted according to patient response and therapeutic goals Initial volume/pressure relationship is based upon normal compliance value, and adjusted according to patient response and therapeutic goals RT 210 Hyperinflation TX

55. IPPB Lab (not notes) Check chart Check chart History History Physical Physical Orders Orders Lab results Lab results Complications Complications Find the proper patient Find the proper patient Identify yourself Identify yourself Ask the patient, "Are you Mr. or Ms. ___________?" Ask the patient, "Are you Mr. or Ms. ___________?" Check the patient's arm band Check the patient's arm band Set up the equipment Set up the equipment Plug in the power source Attach all parts needed Check all settings Addition of medications Addition of medications Proper/appropriate medication checked Draw up and instill in nebulizer Assure proper nebulizer action RT 210 Hyperinflation TX

56. IPPB Lab (not notes) Starting the treatment Starting the treatment Check the patient's name tag again Check the patient's name tag again Hand nebulizer to the patient Hand nebulizer to the patient Instruct the patient in lay terms Instruct the patient in lay terms Set inspiratory peak flow setting Set inspiratory peak flow setting 1/4 to 1/2 turn of knob 1/4 to 1/2 turn of knob use lower flows for new starts use lower flows for new starts Have patient start breathing on circuit Have patient start breathing on circuit Assure seal around mouth piece or mask Assure seal around mouth piece or mask Assure proper adjustments of settings Assure proper adjustments of settings Proper flowrate I:E less then 1:2 Proper flowrate I:E less then 1:2 O2/Air mix O2/Air mix Proper instruction and/or coaching of patient Proper instruction and/or coaching of patient Modification for patient Modification for patient Seal ‑ mp., mask, mouth seal Control of rate Ventilatory pattern Adverse effects Adverse effects Pulse monitored Observation Patient interview Return Demonstration Return Demonstration Vary machines Birds Bennett Vary delivery device Vary orders RT 210 Hyperinflation TX

57. IPPB Lab (not notes) Trouble shoot patient problems Trouble shoot patient problems Hyperventilation Hyperventilation Tachycardia Tachycardia Dyspnea Dyspnea Tingling of fingers Tingling of fingers Diaphoresis Diaphoresis Bradycardia Bradycardia Frank bloody production Frank bloody production RT 210 Hyperinflation TX