1. Volume Expansion Therapy (VET)
RET 2275
Respiratory Care Theory 2

2. Volume Expansion Therapy (VET)
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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. Volume Expansion Therapy (VET)
Hazards & Complications of VET
Ineffective in absence of correct technique (may require repeated instruction & coaching)
Hyperventilation
Exacerbation of bronchospasm

10. Volume Expansion Therapy (VET)
Hazards & Complications of VET
Hypoxemia (if O2 therapy is interrupted)
Barotrauma (in emphysematous lungs)
Fatigue
Pain in postoperative patients

11. 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

12. 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

13. Volume Expansion Therapy (VET)
Incentive Spirometry Equipment
Device is only a visual aid
Importance is placed on patient performing the correct maneuver

14. Volume Expansion Therapy (VET)
Incentive Spirometry (IS)
Equipment
Volume IS

15. Volume Expansion Therapy (VET)
Incentive Spirometry (IS)
Equipment
Flow oriented
(flow x time = volume)

16. 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)

17. 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

18. 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 SMI maneuvers each hour
Once technique is mastered, minimum supervision is required

19. 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

20. Volume Expansion Therapy (VET)
Assessment of Outcome
Normal chest x-ray
Improved oxygenation (PaO2/SpO2)
Return of normal spirometric values
Improved respiratory muscle performance

21. 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

22. 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 = , RR = , 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 Student
Respiratory Care

23. 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

24. 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

25. CPAP Physiological Principles
CPAP elevates and maintains high alveolar and airway pressures throughout the full breathing cycle.

26. 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

27. CPAP
Physiologic Principles - Equipment

28. CPAP Physiologic Principles CPAP
Recruits collapsed alveoli via an increase in FRC

29. 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

30. 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

31. CPAP Contraindications Hemodynamic instability Hypoventilation Nausea
CPAP does not ensure ventilation
Nausea
Facial trauma
Untreated pneumothorax
Elevated intracranial pressure

32. 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

33. 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

34. CPAP
Patient Interfaces
Nasal Mask

35. CPAP Patient Interfaces Fitting the Nasal Mask Use foam bridge
Dorsum of nasal bridge
Around the nasal alae
Mid philtrum
Use foam bridge
Prevents collapse of mask
onto nose

36. CPAP Patient Interfaces Fitting the Nasal Mask DO NOT over tighten
Tissue necrosis

37. CPAP – Tissue necrosis

38. CPAP
Patient Interfaces
Full-Face Mask

39. CPAP Patient Interfaces Fitting the Full-Face Mask Foam bridge
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

40. CPAP Nasal vs. Full-Face Mask Nasal Masks Full-Face Mask
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

41. CPAP
Patient Interfaces
Total Face Mask

42. 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

43. EZ-PAP
EZ-PAP

44. EZ-PAP

45. EZ-PAP with SVN

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

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

48. 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

49. IPPB Indications (AARC)
Short-term nonivasive ventilatory support for hypercapnic patients
Alternative to intubation and continuous ventilatory support

50. IPPB Indications (AARC) The need to deliver aerosol medication
When MDI or nebulizer has been unsuccessful
Patients with ventilatory muscle weakness or fatigue

51. IPPB Contraindications (AARC) Tension pneumothorax ICP > 15 mm Hg
________________________________________
ICP > 15 mm Hg
Hemodynamic instability
Recent facial, oral or skull surgery

52. IPPB Contraindications (AARC) Tracheoesophageal fistula
Recent esophageal surgery
Active hemoptysis
Nausea
Air swallowing

53. IPPB Contraindications (AARC) Active, untreated TB
Radiographic evidence of bleb
Singulus (hiccups)

54. IPPB Hazards (AARC) Increase airway resistance (Raw)
Barotrauma, pneumothorax
Nosocomial infection
Hyperventilation (hypocapnia)
Hemoptysis

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

56. IPPB Hazards (AARC) Exacerbation of hypoxemia Hypoventilation
Increased V/Q mismatch
Air trapping, auto peep, overdistended alveoli

57. IPPB Potential Outcomes Improved IC or VC Increased FEV1 or peak flow
Enhanced cough or secretion clearance
Improved Chest radiograph
Improved breath sounds

58. IPPB Potential Outcomes Improved oxygenation
Favorable patient subjective response

59. IPPB Baseline Assessment Vital signs
Patient’s appearance and sensorium
Breathing pattern
Breath sounds

60. IPPB Implementation Infection control Equipment preparation
Pressure check machine/circuit
Patient orientation
Why MD ordered therapy
What treatment does
How it feels
Expected results

61. IPPB Implementation Application Mouthpiece / nose clip (initially)
Mouthseal
Mask
Trach adaptor

62. 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

63. 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

64. 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

65. IPPB Discontinuation and Follow-Up
Treatments typically last minutes
Repeat patient assessment
Identify untoward effects
Evaluate progress
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