IPPB part I case studies

Elizabeth Kelley Buzbee AAS, RRT NPS, RCP

► Case study # 1 ► Your patient is a 65 year old WF who just had pelvic surgery. She is in traction. To treat her effectively, what do you want to assess at this point?

answer

► VS: HR is 120 bpm, RR 28 bpm ► LOC: she is sleepy and complaining of pain but answers appropriately ► Breath sounds: diminished basal breath sounds and rhonchi and crackles in the upper lobes ► Prior medical history: in good health prior to this surgery

► Based on the data you have collected what else might you want to see?

answer

► Sp02 for s/s of respiratory distress: Sp02 88% ►

Inspection for labored breathing and

for chest wall movement: poor chest wall movement, with substernal retractions ►

► What do you think is wrong with this lady?

answer

► She is suffering post-op atelectasis and she is hypoxic on room air

► What do you want to do for this patient FIRST?

► ANSWER: ► Start 02 to get her Sp02 above 92%

► After you start her on 2 lpm nasal cannula, you see that the Sp02 is still 88%. What do you suggest to the doctor?

► You suggest that we raise the Fi02, you might also ask for an ABG so we can calculate exactly how high to raise the Fi02 ► .

► This is done and you get a Pa02 of 57 torr on 2 lpm. Where do you want to raise the Fi02, based on this new data?

►

answer

Based on Pa02: Fi02 as Pa02 you want : Fi02 you need decide you need a Pa02 80 torr. , you 57 torr : .28 as 80 torr : X 57X = .28 (80) 57X = .28 (80) 57 57 The Fi02 you need = .39

You suggest entrainment mask at 40%

► After she is put on 40% Fi02 her Sp02 is 95% and her respiratory rate drops.

► What do you want to do next?

► ANSWER: ► Start her on IS at 15 ml/kg IBW, assess her breath sounds, VS and respiratory effort for safety and efficacy of the SMI

► How would you assess this patient after IS?

► assess her breath sounds: BS are unchanged after 3 IS TX ► VS: HR and respiratory rate continue to stay high after IS ► respiratory effort for safety and efficacy of the SMI: Still with poor chest movement ► She has a weak cough

► What do you want to assess now in order to treat this patient effectively?

answer

► Look at the X-Ray: the atelectasis has spread from the one seen on the first day ► What is her IC on the IS?: the IC she gets on the IS is only 8 ml/kg IBW

► Based on the information in the last slide, what do you want to suggest to the doctor?

answer

► She needs IPPB at Air/Mix to deliver a Vt of at least 15 ml/Kg/ IBW ► The doctor orders 2.5 mg of Albuterol in 2.5 ml of normal saline

► How would you assess the safety & effectiveness of this therapy?

answer

► ► ► ►

Measure the exhaled Vt to make sure she is getting at least 15 ml/Kg IBW and that she is not exceeding 45 ml/Kg IBW:

 she is getting 25 ml/kg IBW at a pressure of 18 cmH02

VS before, 3 minutes into and after IPPB.

 Her HR was 115, rose to 125 in 3 minutes and was 145 after the IPPB. Her respiratory rate on the IPPB is 15 bpm

Breath sounds before and after IPPB:

 Breath sounds increased in basal posterior

Cough?

 Strong cough with copious, thick green sputum

► How do you want to modify her TX at this point?

Answer:

► Her Vt is ok ► Her respiratory rate on the IPPB needs to be 6-8 bpm to give her heart time to refill ► To make sure that Albuterol is not causing the HR increase, stop TX after 3 minutes and see if the HR decreases back to baseline ► To make the thick secretions thinner, suggest Acetylcysteine

Case study # 2

► Your patient is a 55 year old LAM who is 5’ 8’’ tall. He has been admitted for biopsy of the lung for possible lung CA [cancer] ► How do you want to assess this gentleman

Answer:

► ► ► ► ► prior medical history:  history of working with asbestos   20 pack/year smoking history Chronic bronchitis for several years Inspection for s/s respiratory distress  Respiratory rate 18 bpm and with no use of accessory muscles  HR 110 bpm Breath sounds :  Scattered rhonchi to all lobes and wheezes over the RML. A plural rub over the LLL.

Sp02 :

 Sp02 is 93% on Room Air

Sputum production

 Scanty, thick, yellowish sputum

► What do you suggest to treat him at this point?

► He doesn’t need 02 right now, but he needs a beta II bronchodilator and possibly a mucolytic by SVN. ► After his surgery, he may need IS so you could start him on IS to train him prior to surgery

► The patient goes to surgery and gets a biopsy from his Right Middle Lobar bronchus. ► In recovery room, he is sleepy and you start him on IS. He only gets 8 ml/kg IBW ► What do you want to assess right now?

Answer:

► Before you decide to give him IPPB, you need to look at his post-op X-Ray to rule out the presence of a pneumothorax  He has no pneumothorax ► You want to check for blood in his sputum  He coughs up a teaspoon of bloody sputum during his IS

► What do you want to do now?

Answer:

► IPPB is contraindicated in Hemoptysis and he has bloody sputum. ► We need continue with the SVN with beta II drug, and use segmental breathing, ► but we might have to consider decreasing the concentration of the Acetylcysteine from 20% to 10% [add normal saline] because Acetylcysteine can make bleeding worse by triggering violent coughing

Case study # 3

► Your patient is a 45 year old WM who is status post [s/p] multiple trauma from a MVA [moving vehicular accident] ► How do you want to assess this patient?

Answer:

► ► ► ► ► ► Check chart for history of current illness [extent of injuries]  Broken ribs, chest tube placed to drain hemothorax.

VS:  RR 25, HR 118 bpm Inspection for s/s of respiratory distress  Shallow breathing, no retractions, no flaring Sp02:  Sp02 91% on 40% Percussion  No hyper-resonance over the chest BS:  Diminished BS over the LLL [area of chest tube] diminished over RLL. Rhonchi over RUL

► What else might be assessed?

answer

► X-ray shows:  LLL effusion, presence of chest tube in the lower portion of the chest ► Check history:   no prior cardiopulmonary history IBW 65 kg

► What do you want to treat ?

answer

► Start supplemental 02 to get the Sp02 above 92% ► Initiate coughing, deep breathing ► start IS at a minimal IC of 780-975 ► If reassess BS and cough effort after IS to see if patient might need mucolytics via SVN

► After the first IS, the patient can only get 600 ml, but he is c/o pain on inspiration ► What do you do?

answer

► Get with nurse regarding his pain medication schedule ► Schedule IS to match his pain-free time

► Patient’s pain medication is increased and he is sleepy and co-operative. ► After three more IS, you note that his IC is still only 600 ml.

► What else do you need to assess?

answer

► His cough effort:  Weak and unproductive ► His VS: HR 125 RR 29 bpm ► His BS:   Diminished basal BS Rhonchi and crackles over the middle and upper lobes ► His X-ray   The effusion has almost resolved Atelectasis in the LLL and the RLL

► What do you want to do now?

answer

► Start IPPB at 975 ml to treat atelectasis  Follow-up X-ray and BS to assess ► Give beta II drug with normal saline  Follow-up BS and VS to effectiveness and safety