1. IPPB vs. EzPap
Ruby Bueno, Michael Cua, Sherria Miller, Myaa Smith, and Subrina Vohra
Lonestar-Kingwood College respiratory Care Program
Respiratory Care
Facilitator: Elizabeth Kelley Buzbee, AAS-RRT-NPS, RCP

2. Abstract
We conducted our study on 10 healthy individuals. The data we gathered included our study participants vital signs, tidal volumes, and peak flows. Each participant first used the IPPB and then the EzPap. Then we compared their peak flows after each use. One of our limitations was that we conducted our research on healthy participants. Each participant did not show that much of a change in percentage. We believe if the study had been conducted on participants with lung disorders there would have been a true comparison.

3. Hypothesis
IPPB will increase peak flow results when compared to EZPAP treatments in healthy adults.

4. IPPB

5. IPPB Background
IPPB is indicated for the need to improve lung expansion. Patients who cannot cooperate to therapy are also candidates for IPPB(AARC,2003). IPPB is also indicated for patients who have the inability to clear secretions due to a certain disease that severely limit themselves to ventilate or cough on their own (AARC,2003). IPPB is also indicated to deliver aerosol medication (AARC,2003). In a healthy person, it can cause barotrauma or pneumothorax, physiological dependence, nosocomial infections, hypocarbia, hypo- or hyper- ventilation, increased mismatch of ventilation or perfusion and gastric distention (AARC, 2003).
Moreover, IPPB could be very hazardous to people with disorders. It could cause an increase airway resistance in persons with disorder that lead to air trapping, hemoptysis in individuals with blood disorders, hyperoxia in persons with poor oxygenation, and impedance of venous return that is associated with individuals with hypotension. In patients that have obstructive disorders such as asthma and COPD, it could cause exacerbation of the disorder, auto-PEEP, over distention of the alveoli and air trapping (AARC, 2003). It could also cause impaction of secretions associated with adequately humidified gas mixture when used for an extended period of time.
There are many contraindications for IPPB use such as tension pneumothorax, ICP greater than 15mmhg, hemodynamic instability and having recent facial or skull surgery. Those who may have a tracheoesophageal fistula or recent esophageal surgery are included in those who cannot benefit from the IPPB. Other contraindications are ones with active hemoptysis, nausea, air swallowing and active untreated tuberculosis.
IPPB can deliver large volumes of gas through circuits to patients via mask, mouth piece, nebulizer or HME. IPPB can cause problems with excessive volume if return tidal volumes are not measured.

6. EZPAP

7. EZPAP Background
EZPAP is indicated to treat, prevent and reverse atelectasis. It is also used to mobilize retained secretions, reduce air trapping and is used as an aerosol medication delivery device adjunct.
As with other devices, EZPAP also does have hazards and complications associated with its use. In healthy patients it can decrease venous return and cause claustrophobia. In compromised patients it can increase the work of breathing that can lead to hypercarbia and hypoventilation, increased intracranial pressure, cardiovascular instability and myocardial ischemia. Air swallowing with an increased likelihood of vomiting and aspiration as well as pulmonary barotrauma can also be seen in compromised patients.
There are also many contraindications for ezPap which include an increased work of breathing, ICP greater than 20mmhg, hemodynamic instability as well as having recent facial or skull surgery. Having acute sinusitis, epitaxis, esophageal surgery are also contraindicated. Those who have active hemoptysis, nausea, tympanic membrane rupture and untreated pneumothorax can also be included as a contraindication for the ezPap.
EZPAP uses May be use with a mask or nebulizer. EZPAP can have problem if set higher than 12 liters per minute will develop high pressures and there are potential problems with defective EZPAP manometers

8. Methodology Positive Airway Pressure Device Ambient Air Inlet
1. EZPAP
Positive Airway Pressure Device
Ambient Air Inlet
Gas Inlet Port
Pressure Monitoring Port with Cap
Patient interface – mouthpiece
7 foot O2 tubing to connect gas inlet port to wall flow meter
Intended use: EzPap is indicated for use in conjunction with a medical need for lung expansion therapy and the treatment and prevention of atelectasis. EzPap may be used with nebulizer between patient and device. EzPap is also available with various mask sizes.

9. Methodology cont.
Set up: Connect one end of tubing to a lpm flow meter that is connected to psi medical air. Connect the patient end of tubing coming from the flow meter to the device’s gas inlet port. Connect the device pressure port to a pressure gauge. This is recommended for initial set-up to become aware of pressures transmitted to the patient. If pressure monitoring is not being done, seal port with attached pressure monitoring port cap. Pressure monitoring port should not be exposed to ambient air while in use. Attach the mouthpiece to rounded end of the device. Serrated end is to be exposed to ambient air at all times. DO NOT OCCLUDE.
Manufacturer: Smiths Medical ASD Inc
10 Bowman Drive
Keene, NH USA

10. Methodology cont. 2. IPPB (BIRD MARK 7)
Bird Mark 7 - have two connections on the right side of the machine (the pressure side): a large-bore connection for the main breathing hose and one small connection for a single drive line. This line splits at the nebulizer to power both the nebulizer and the exhalation valve. A splitting device fits over the connection on the nebulizer. The drive line connects to this device, and the short piece of tubing connects to
Positive Airway Pressure Device
Ambient Chamber
Gas source inlet

11. Methodology cont. Pressure Manometer
IPPB Machine is connected to a 50 psig gas source with high-pressure hose.
Set up: IPPB BIRD 7 machines have a connection for the large-bore tubing, which is usually attached before being packaged, and a connection on the nebulizer for the line splitter. Attach the tubing to the appropriate connections on the respirator, making sure all connections are tight. The connections and tubing are sized so that only the correct tubing will fit on the connector. Attach the tubing to the nebulizer and exhalation valve assembly. Again the tubing and connections are sized to prevent incorrect assembly. The small drive line is attached to the line splitter. The short piece of tubing on the line splitter connects to the exhalation valve. Attach the patient connection to the nebulizer assembly. Most disposable circuits come with a six-inch length of large-bore tubing which provides a reservoir for medication and connects the mouthpiece or other device to the nebulizer.
Manufacturer: Bird Products Corporation
1100 Bird Center Drive
Palm Springs, CA, 92262

12. Methodology cont.
3. PEAK FLOW (Respironics Personal Best Peak Flow Meter)
A peak flow measures how fast air flows from your lungs. It's a small device that you are able to hold in your hand. It's also portable so it can be used for bedside. The peak flow meter is known to assist in the management of the asthmatic patients. If any changes are needed with their medications, then monitoring the patient's peak flow measurements would not be a useful tool.
Available in both full range (60 – 810 l/min) and low range (50 – 390 l/min).
Manufacturer: Respironics Houston (RIHS)
3605 Willowbend, Suite 500
Houston, TX 77054

13. Methodology cont. Protocol (Experiment) for Methodology
After obtaining informed consent, explaining the procedure to the test subject, performing a physical exam with a complete medical history, and getting approval from the institutional review board, we then conducted our research.
Subject Selection:
No specific age. Adults only
Healthy adults of both sexes
Subjects were selectively chosen from a small population, rural college and the local community.
Subjects were selected on health only. Anyone was able to participate as long as they were healthy adults without any major health restrictions. If the subject had any condition that could complicate their health or the study, he/she was eliminated from the study.

14. Methodology cont.
Prevented disconnection of equipment during usage, made sure all tubing and connections were securely attached.
Projected times:
1. Explained procedures, answered questions and signed consents – minutes
2. Pt filled out questionnaire – 10 minutes
3. Vital signs and peak flows were done – 5 minutes
4. IPPB performed – 10 breath cycles for 1 to 2 minutes
5. There was a 1 minute break
6. Checked Peak flows and documented – 2 minutes
7. There was a 5 minute break between each equipment use
8. EZ Pap performed – 10 breath cycles for 1 to 2 minutes
9. There was a 1 minute break
10. Checked Peak flows and documented – 2 minutes
Aseptic technique was used between each equipment use and in between each patient.
There were disposable bacterial filters and tubing for the EZ Pap and IPPB machine.

15. Patient Code
Peak Flow Results
Percent (%) Change
IPPB
EzPap
Z001
475
460
-3.16
Z002
350
400
14.29
Z003
330
Z004
345
-27.37
Z005
385
410
6.49
Z006
280
270
-3.57
Z007
340
300
-11.76
Z008
n/a
Z009
Z010
470
Z011
375
355
-5.33
This table displays the results for each study participants percent change after usage of the IPPB and EzPap. As seen here, due to one of our limitations, there was not that much of a significant percent change for each study participant except for participant Z004. Participant Z008 was unable to conduct the study due to information given that they had protruding veins coming from their head and getting lightheaded while performing one of the other studies.

16. Peak Flow
Patient Code
Expected PF
1st PF
2nd PF
3rd PF
Peak Flow Results
IPPB
EzPap
Z001
638
460
475
490
Z002
448
360
390
400
350
Z003
375
320
330
Z004
385
290
345
Z005
565
430
410
Z006
275
280
270
Z007
386
300
325
340
Z008
n/a
Z009
497
334
310
Z010
622
450
480
470
Z011
469
355
AVERAGE (MEAN)
477
356.4
364
372
378
RANGE
MEDIAN
458.5
327.5
362.5
This table displays the averages, ranges and median of the peak flows as well as the results from each of our study participants. We found the each participants expected peak flow and then had them perform three peak flows simultaneously before they used the IPPB and EzPap. We recorded each of them. As for the results, we recorded only the best out of the three peak flows for each participant. The best one after the IPPB was performed and the best one after the EzPap was performed.

17. This graph shows the difference in each study participants peak flows
This graph shows the difference in each study participants peak flows. The blue bars are for the IPPB and the green bars are for the EzPap. There were 10 study participants. Out of the 10, 5 of them did better with IPPB; 2 did better with EzPap; and 3 of them showed no difference.

18. Limitations
Money
Time
Unhealthy patients

19. Recommendations
We would like a research group to mimic our study on patients:
With COPD
With Asthma
After bronchodilator treatments

20. Conclusion
Based on the results from our research, we found that IPPB improved peak flows more than EzPap. With the patients that we have chosen, the difference was very minimal.

21. Glossary AARC – American Association of Respiratory Care
Acapella – A small PEP device that helps to mobilize secretions by providing positive expiratory pressure (PEP) therapy and airway vibrations.
Alveoli – any of the small thin-walled air-containing compartments of the lung that are typically arranged in saclike clusters into which an alveolar duct terminates and from which respiratory gases are exchanged with the pulmonary capillaries
Ambulatory – Refers to the ability to walk.
Asthmatic – A chronic respiratory disease, in which the airways unexpectedly and suddenly narrow
Atelectasis – collapse of the expanded lung; defective expansion of the pulmonary alveoli
Auscultation – Listening for sounds within the body, especially from the chest, neck, or abdomen. A stethoscope is typically used.
Barotrauma – Injury caused by increased air or water or pressure
Bronchodilator – A drug that expands he bronchi by relaxing bronchial muscles.

22. Glossary cont.
COPD- (chronic obstructive pulmonary disease) a progressive lung disease process characterized by difficulty breathing, wheezing, and a chronic cough
CPT Chest physiotherapy; technique used to mobilize or loose secretions in the lungs and respiratory tract.
Dyspnea-Air hunger resulting in labored breathing or difficult breathing, sometime accompanied by pain
EKG (Electrocardiogram) – A record of the electrical activity of the heart consisting of waves called P, Q, R, S, T and sometimes U.
Emesis – Vomiting. It may be of gastric, systemic, or neurological origin.
Exacerbation-Worsening or a “flare up” of COPD
Fistula- an abnormal connection between two organs, or between an organ and the outside of the body
Gastric-Stomach

23. Glossary cont. Hemoptysis-Blood spitting, the act of coughing up blood
Hypercapnia – An increase in the partial pressure of carbon dioxide in the blood, typically to levels greater than mmHg.
Hyperoxia-An excess of oxygen in the system
Hyperventilation – Excessive ventilation; excessive rate and depth of respirations leading to loss of carbon dioxide from the blood
Hypocarbia - Less than normal level of carbon dioxide in the blood.
Hypoventilation- deficient ventilation of the lungs that results in reduction in the oxygen content or increase in the carbon dioxide content of the blood or both
Hypoxemia-A deficiency in the concentration of dissolved oxygen in arterial blood
Infiltrates- Allowing dirt and water to enter into something
Intracranial pressure- Pressure of the cerebrospinal fluid in the head with sensor inserted through the skull

24. Glossary cont.
Intubation-The insertion of a tube into any hollow organ. Intubation of the trachea provides an open airway and thus is an essential step in advanced life support.
IPPB- Intermittent positive pressure ventilation
IS – (incentive spirometry); also referred to as sustained maximal inspiration (SMI), is a component of bronchial hygiene therapy
Kyphoscoliosis- Lateral curvature of the spine accompanied by the anterioposterior hump.
MDI- ( metered dose inhaler)small aerosol canister in a plastic container that releases a mist of medication when pressed down from the top. This medication can be breathed into the airways
Mechanical ventilation-Artificially inflating and deflating the lungs to force gas exchange in the lungs
Nebulizer-An apparatus for producing a fine spray or mist. This may be done by rapidly passing air through a liquid or by vibrating a liquid at a high frequency so that the particles produced are extremely small.
Neuromuscular-Concerning both nerves and muscles

25. Glossary cont.
Nosocomial infections-Any infection that first occur during a patient’s stay at a health-care facility, regardless of whether it was detected during or after the stay.
NPPV (non-invasive positive pressure ventilation); refers to delivery of ventilatory support using a mechanical ventilator connected to a mask or mouthpiece instead of an endotracheal tube.
Peak Flow-A peak flow meter is a small, hand-held device used to manage asthma by monitoring airflow through the lungs
PEEP Positive end expiratory pressure; term used in mechanical ventilation to denote the amount of pressure above atmospheric pressure present in the airway at the end of the expiratory cycle
PEP – Positive Expiratory Pressure
Perfusion- An act of perfusing the pumping of a fluid through an organ or tissue
Pneumothorax- accumulation of air or gas in the pleural cavity.
Pneumatically-Powered by compressed air

26. Glossary cont.
Spirometer- A spirometer is an instrument for measuring the volume of air inspired and expired by the lungs.
Sputum – Mucus expelled from the lung by coughing. It may contain a variety of materials from the respiratory tract, including in some instances cellular debris, mucus, blood, pus, caseous material and/or microorganisms.
Stethoscope – An instrument used to transmit o the examiners ears sounds produced in the body. It ordinarily consists of rubber tubing in a Y shape and a bell or diaphragm.
TB (tuberculosis)-A disease caused by the bacterium Mycobacterium tuberculosis that usually causes an infection of the lungs.
Venous- Venous blood is blood returning to the heart in veins.
Ventilation- The movement of air into and out of the lung
Wheezing- A wheeze is a continuous, coarse, whistling sound produced in the respiratory airways during breathing Infiltrates- Allowing dirt and water to enter into something

27. Bibliography
AARC. (2003).AARC clinical practice guideline: intermittent positive pressure breathing-2003 revision and update. Respiratory Care, 48(5),
AARC. (1993). AARC clinical practice guidelines: use of positive airway pressure adjuncts to bronchial hygiene therapy. Respiratory Care, 38(5), .
van der Scahans, Cees P.(2007) Conventional chest physical therapy for obstructive lung disease. Respiratory Care, 52(9),
Taber, Clarence Wilbur. (2005). Taber’s cyclopedic medical dictionary (Ed. 20). Philadelphia: Davis Co.

28. THE END