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Volume Expansion Therapy (VET)
RET 2275
Respiratory Care Theory 2
Volume Expansion Therapy (VET)
Volume Expansion Therapy
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)
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
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
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
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
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
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)
Volume Expansion Therapy (VET)
Hazards & Complications of VET
Ineffective in absence of correct technique (may
require repeated instruction & coaching)
Hyperventilation
Exacerbation of bronchospasm
Volume Expansion Therapy (VET)
Hazards & Complications of VET
Hypoxemia (if O2 therapy is interrupted)
Barotrauma (in emphysematous lungs)
Fatigue
Pain in postoperative patients
Volume Expansion Therapy (VET)
Assessment of Need
Evidence of atelectasis based on physical exam & xray findings
Upper abdominal or thoracic surgery
Presence of predisposing conditions
Presence of neuromuscular disease affecting the
respiratory muscles
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
Volume Expansion Therapy (VET)
Incentive Spirometry Equipment
Device is only a visual aid
Importance is placed on patient performing the correct
maneuver
Volume Expansion Therapy (VET)
Incentive Spirometry (IS)
Equipment
Volume IS
Volume Expansion Therapy (VET)
Incentive Spirometry (IS)
Equipment
Flow oriented
(flow x time = volume)
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)
Volume Expansion Therapy
Incentive Spirometry (IS)
Administering IS
RT should set initial goal (e.g. certain volume)
Instruct patient to inspire SLOWLY and deeply
Should require some moderate effort
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
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 5 10 SMI maneuvers each hour
Once technique is mastered, minimum supervision is
required
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
Volume Expansion Therapy (VET)
Assessment of Outcome
Normal chest x-ray
Improved oxygenation (PaO2/SpO2)
Return of normal spirometric values
Improved respiratory muscle performance
Volume Expansion Therapy
Incentive Spirometry (IS)
Charting IS
Pre-treatment vital signs
Initial goal
HR, RR, Breath sounds
Example: 800 ml x 10 SMI
Patient toleration
Post-treatment vital signs
Patient education
See examples of charting notes on next slide
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 = 80 - 72,
RR = 16 - 14, 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
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
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
CPAP
Physiological Principles
CPAP elevates and maintains high alveolar and
airway pressures throughout the full breathing cycle.
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
CPAP
Physiologic Principles - Equipment
CPAP
Physiologic Principles
CPAP
Recruits collapsed alveoli via an increase in FRC
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
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
CPAP
Contraindications
Hemodynamic instability
Hypoventilation
CPAP does not ensure ventilation
Nausea
Facial trauma
Untreated pneumothorax
Elevated intracranial pressure
CPAP
Hazards and Complications
Increased work of breathing caused by the apparatus
Patients with ventilatory insufficiency may
hypoventilate during application
Barotrauma
Hypoventilation and hypercapnia
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
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
CPAP
Patient Interfaces
Nasal Mask
CPAP
Patient Interfaces
Fitting the Nasal Mask
Dorsum of nasal bridge
Around the nasal alae
Mid philtrum
Use foam bridge
Prevents collapse of mask
onto nose
CPAP
Patient Interfaces
Fitting the Nasal Mask
DO NOT over tighten
Tissue necrosis
CPAP – Tissue necrosis
CPAP
Patient Interfaces
Full-Face Mask
CPAP
Patient Interfaces
Fitting the Full-Face Mask
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
CPAP
Nasal vs. Full-Face Mask
Nasal Masks
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
CPAP
Patient Interfaces
Total Face Mask
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
EZ-PAP
EZ-PAP
EZ-PAP
EZ-PAP with SVN
IPPB
Definition
The application of inspiratory positive pressure
to a spontaneously breathing patient as an
intermittent or short-term therapeutic modality
IPPB
Definition
The delivery of a slow deep sustained
inspiration by a mechanical device providing
controlled positive pressure breath during
inspiration
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
IPPB
Indications (AARC)
Short-term nonivasive ventilatory support for
hypercapnic patients
Alternative to intubation and continuous
ventilatory support
IPPB
Indications (AARC)
The need to deliver aerosol medication
When MDI or nebulizer has been unsuccessful
Patients with ventilatory muscle weakness or
fatigue
IPPB
Contraindications (AARC)
Tension pneumothorax
________________________________________
ICP > 15 mm Hg
Hemodynamic instability
Recent facial, oral or skull surgery
IPPB
Contraindications (AARC)
Tracheoesophageal fistula
Recent esophageal surgery
Active hemoptysis
Nausea
Air swallowing
IPPB
Contraindications (AARC)
Active, untreated TB
Radiographic evidence of bleb
Singulus (hiccups)
IPPB
Hazards (AARC)
Increase airway resistance (Raw)
Barotrauma, pneumothorax
Nosocomial infection
Hyperventilation (hypocapnia)
Hemoptysis
IPPB
Hazards (AARC)
Hyperoxia when O2 is the gas source
Gastric distention
Secretion impaction (inadequate humidity)
Psychological dependence
Impedance of venous return
IPPB
Hazards (AARC)
Exacerbation of hypoxemia
Hypoventilation
Increased V/Q mismatch
Air trapping, auto peep, overdistended alveoli
IPPB
Potential Outcomes
Improved IC or VC
Increased FEV1 or peak flow
Enhanced cough or secretion clearance
Improved Chest radiograph
Improved breath sounds
IPPB
Potential Outcomes
Improved oxygenation
Favorable patient subjective response
IPPB
Baseline Assessment
Vital signs
Patient’s appearance and sensorium
Breathing pattern
Breath sounds
IPPB
Implementation
Infection control
Equipment preparation
Pressure check machine/circuit
Patient orientation
Why MD ordered therapy
What treatment does
How it feels
Expected results
IPPB
Implementation
Application
Mouthpiece / nose clip (initially)
Mouthseal
Mask
Trach adaptor
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
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
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
IPPB
Discontinuation and Follow-Up
Treatments typically last 15-20 minutes
Repeat patient assessment
Identify untoward effects
Evaluate progress
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