HYPERINFLATION THERAPY

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CHAPTER 7 HYPERINFLATION THERAPY

PRETEST QUESTIONS

Answer the pretest questions before studying the chapter. This will help you determine your strong and weak areas in the material covered.

1. Which of the following increases the delivered VT to a patient taking an IPPB treatment with the Bird Mark 7 IPPB machine?

1. Increasing flow rate
2. Increasing inspiratory pressure
3. Decreasing sensitivity
4. Decreasing flow rate
A. 1 and 2 only
B. 1 and 3 only
C. 2 and 4 only
D. 1, 2, and 3 only

2. During an IPPB treatment, the patient suddenly complains of chest pain and becomes short of breath. On assessing the patient, you auscultate the chest and hear decreased breath sounds on the left. These findings are consistent with which of the following?

A. Atelectasis
B. Left-sided pneumothorax
C. Pulmonary embolism
D. Pleural effusion

3. The respiratory therapist is administering IPPB, and the patient complains of feeling light-headed and dizzy. What should the therapist do to correct this?

A. Instruct the patient to pause longer between breaths.
B. Instruct the patient to take deeper breaths.
C. Increase the inspiratory pressure.
D. Decrease the inspiratory flow.

4. While the respiratory therapist is administering IPPB, the patient begins coughing up large amounts of blood. The therapist should

A. Continue the treatment and notify the physician that a chest radiograph is needed.
B. Decrease the inspiratory pressure.
C. Stop the treatment briefly and resume it when the patient is feeling better.
D. Stop the treatment and notify the physician.

5. Which of the following are hazards of IPPB therapy?

1. Excessive ventilation
2. Increased cardiac output
3. Decreased ICP
A. 1 only
B. 2 only
C. 1 and 3 only
D. 2 and 3 only

6. The respiratory therapist has received an order to deliver IPPB to a patient with head trauma. What modifications in therapy may benefit this patient?

1. Use a higher flow rate.
2. Use lower peak pressures.
3. Set the sensitivity to −5 cm H2O.
A. 1 only
B. 2 only
C. 1 and 2 only
D. 2 and 3 only

7. Incentive spirometry is ordered for a patient after abdominal surgery. Which of the following statements by the respiratory care practitioner would be most appropriate in the initial explanation of the therapy to the patient?

A. “You may experience pain and light-headedness from this therapy.”
B. “We are trying to improve your inspiratory capacity.”
C. “This therapy will help you take deep breaths and expand your lungs.”
D. “Your doctor has ordered this therapy to prevent atelectasis.”

8. Sustained maximal inspiratory maneuvers performed with an incentive spirometer would be MOST effective in the

A. Treatment of pneumonia.
B. Prevention of pneumonia.
C. Treatment of preexisting atelectasis.
D. Prevention of atelectasis.

9. The initial inspiratory goal for a patient receiving incentive spirometry should be

A. Twice the patient’s measured tidal volume.
B. Equal to the patient’s measured tidal volume.
C. At least 1500 mL.
D. 5 mL/kg of body weight.

See answers and rationales at the back of the text.

REVIEW

I. INTRODUCTION TO IPPB THERAPY

CRT Exam Content Matrix: IIA6a, IIA11b, IIB5, IIIA1a-b, IIID2a, IIIF1, IIIF2a

RRT Exam Content Matrix: IIA2a, IIIA1a-b, IIID2a, IIIF1, IIIF2a

A. IPPB is defined as a short-term (10 to 15 min) breathing treatment in which pressures above atmospheric pressure are delivered to the patient’s lungs via a pressure-limited ventilator.
B. Effective IPPB depends on four factors
1. A respiratory therapist who has been well trained and has a knowledge of the equipment, medications used, reasons for therapy, and side effects and goals of therapy
2. A relaxed, informed, and cooperative patient
3. A pressure-limited IPPB machine with a means of measuring VT
4. Proper instruction of the patient on breathing patterns and cough techniques by the respiratory therapist

II. PHYSIOLOGIC EFFECTS OF IPPB

A. Increased Mean Airway Pressure
1. During normal spontaneous inspiration, airway pressure drops below atmospheric pressure (−2 cm H2O), thereby setting up a pressure gradient between the atmosphere (at nose and mouth) and the airways. Air flows into the airways, gradually building pressure back up to atmospheric level. Air flow stops, and passive exhalation occurs as a result of the natural recoil properties of lung tissue. The lung is never subjected to significant positive pressure.
2. During an IPPB machine breath, positive pressure is applied to the airways to improve the ventilation status of the lung. This is what is meant by “increased mean airway pressure”; it is the average (mean) pressure in the airways during one breathing cycle.
B. Increased VT
1. IPPB should deliver a VT of 12 to 15 mL/kg of ideal body weight.
2. Delivered VT depends on the patient’s lung status (e.g., compliance and airway resistance).
a. Decreased compliance results in a decreased delivered VT.
b. Increased compliance results in an increased delivered VT.
c. Decreased airway resistance results in an increased delivered VT.
d. Increased airway resistance results in a decreased delivered VT.
3. Delivered VT may be measured with a respirometer or gas-collection bag on the exhalation port.
4. The inspiratory pressure control adjusts the delivered VT.
a. Increase pressure to increase delivered VT.
b. Decrease pressure to decrease delivered VT.
C. Decreased Work of Breathing
1. A patient experiencing acute hypoventilation may avoid intubation and use of a mechanical ventilator (possibly only temporarily) by administration of frequent IPPB treatments.
2. The practitioner must encourage the patient to relax and allow the IPPB unit to do all the work for the patient’s work of breathing to decrease.
3. IPPB may increase the patient’s work of breathing if
a. The machine sensitivity (triggering mechanism) is set too low, making it difficult for the patient to cycle the machine into inspiration. The patient should be required to pull no more than −2 cm H2O of pressure to initiate inspiration.
b. The flow rate is inadequate to meet the patient’s inspiratory flow demands. Increase the flow rate if inspiratory time is prolonged and if the manometer needle is rising slowly or lagging to peak pressure. Another indication that the flow is inadequate is if the manometer needle remains near zero throughout most of the inspiration and then rises quickly to peak pressure.
c. The delivered VT is inadequate. Monitor the VT and listen to basilar breath sounds to ensure adequate volumes are being delivered.
d. Adequate time is not allowed for passive exhalation to occur. The machine sensitivity (triggering mechanism) may be set too high, which may result in self-cycling.

D. Alteration of the Inspiratory and Expiratory Time
1. When a patient with respiratory difficulties receives IPPB, the alveolar ventilation should be improved, thereby making the patient more comfortable, less “air hungry,” and returning the inspiration:expiration (I:E) ratio and respiratory rate to normal.
2. The normal I:E ratio for an adult is 1 : 2.
E. Mechanical Bronchodilation
1. A patient with respiratory disease experiences an increased resistance to air flow as the diameter of the airways decreases as a result of bronchospasm, secretions, and other factors.
2. When positive pressure is applied to constricted airways, dilation of these airways can occur to a greater degree than with spontaneous breathing.

image Some studies show that higher flow rates and pressures may cause a bronchoconstrictive reflex in the airways. This may be counteracted by administering bronchodilating agents.

F. Cerebral Blood Flow Alteration
1. A patient receiving IPPB may experience light-headedness, dizziness, or faintness from reduced PaCO2 levels and the resultant alkalemia. Decreased PaCO2 levels result in cerebral vasoconstriction, thus decreasing cerebral blood flow.
2. To prevent reduced PaCO2 levels, encourage the patient to breathe slowly and to pause between breaths.
3. A 50-mL flex tube should be connected between the mouthpiece and manifold, allowing a slight rebreathing of CO2 and preventing decreased PaCO2 levels.

III. INDICATIONS FOR IPPB THERAPY

A. Increased work of breathing
B. Hypoventilation
C. Need for delivery of medications to a patient who cannot take a deep breath (10 to 15 mL/kg of ideal body weight)
D. Inadequate cough
E. Increased airway resistance
F. Atelectasis, especially in sedated postoperative patients and patients recovering from chest or abdominal surgery who are reluctant to breathe deeply
G. Pulmonary edema
H. Need for aid in weaning from continuous mechanical ventilation

IV. HAZARDS OF IPPB THERAPY

A. Excessive Ventilation
1. Leads to decreased PaCO2 levels, causing cerebral vasoconstriction and resulting in dizziness
2. Patient should be instructed not to stand or walk immediately after the treatment.
B. Excessive Oxygenation
1. Patients with severe COPD may breathe by the “hypoxic drive” mechanism. If the IPPB treatment is given with O2, it may elevate the PaO2 above the normal level (50 to 65 mm Hg), which may knock out the patient’s drive to breathe.

image Exam Note

Although the “hypoxic drive” theory is highly debated and its validity is often questioned, the exam may still ask questions dealing with this subject.

2. Hypoxic drive potential is indicated by the following ABG levels: pH, 7.35 to 7.40 (compensated); PaCO2, more than 50 mm Hg; PaO2, less than 65 mm Hg.
C. Decreased Cardiac Output
1. Positive pressure applied to the airways is likewise exerted on blood vessels returning blood to the heart. This restricts venous blood return to the heart, which in turn decreases cardiac output from the left ventricle.
2. Avoiding high inspiratory pressures and long inspiratory times minimizes this hazard.
3. If there is a decreased venous return during the therapy, the patient may experience tachycardia and a decrease in systemic blood pressure, which is caused by decreased left ventricular filling pressure.
D. Increased ICP
1. Blood flow from the head is restricted as positive pressure is exerted on the superior vena cava, which is returning blood to the heart from the upper body. This keeps more blood in the cerebral vessels, which elevates ICP levels.
2. Normal ICP is less than 10 mm Hg.
3. Using lower pressures and shorter inspiratory times (increased flows) and having the patient positioned in the Fowler position or sitting on the edge of the bed minimizes this hazard.
4. This is not a common hazard, except in patients with closed head injuries or CNS disease.
E. Pneumothorax
1. Most common in patients with COPD with bullous disease or emphysema with bleb formation.
2. Patients who complain of sudden chest pain, shortness of breath, or other breathing difficulties and who have tachycardia during IPPB must be suspected of having a pneumothorax.
3. Listen with a stethoscope for bilateral breath sounds and observe for asymmetric chest movement.
4. If pneumothorax is suspected, the treatment must be stopped immediately.
F. Hemoptysis
1. The coughing up of blood during or after IPPB may not be caused by IPPB itself but may be related to a strong cough accompanying the treatment.
2. The treatment must be stopped immediately because air could be forced into a blood vessel, resulting in an air embolism.
G. Gastric Distention
1. Caused by swallowing air during the treatment.
2. May cause the patient to complain of nausea during or after the treatment.
H. Nosocomial Infection
1. Circuits should be changed every 24 h.
2. Appropriate filters should be used on the IPPB unit to prevent machine contamination.
3. Practitioners should wash their hands before and after every treatment.

V. CONTRAINDICATIONS TO IPPB THERAPY

A. Untreated Pneumothorax: Absolute Contraindication
1. IPPB should not be administered under any circumstances with this condition because it only worsens the problem.
2. IPPB is safe for patients with a pneumothorax who have a chest tube in place.
B. Pulmonary Hemorrhage: Absolute Contraindication
1. If IPPB is administered in this situation, air may enter a blood vessel, resulting in an air embolism.
C. Relative Contraindications (under certain circumstances IPPB may be administered or the therapy may be modified)
1. Tuberculosis
a. May lead to the spread of the disease, if the patient is not receiving antituberculosis medications.
b. IPPB is safe if the patient is receiving such drugs.
2. Subcutaneous emphysema
a. Indicates an air leak from the lung, and further positive pressure would worsen the condition.
b. This condition is not a danger in itself, but it may be an indication of a more severe condition, such as pneumothorax or pneumomediastinum.
3. Hemoptysis
a. This condition indicates an open pulmonary blood vessel, which could lead to an air embolism.
b. The origin of the bleeding must be determined.
4. Closed head injury
a. IPPB may increase ICP; therefore ICP must be monitored closely during IPPB in these patients.
b. To lessen the potential of increasing ICP, use higher flow rates (decreased inspiratory time) and lower peak pressures.
5. Bullous disease
a. Patients with bullae or bleb formation, such as those with COPD, are more susceptible to a pneumothorax. Bullae and blebs constitute weak air spaces and rupture easily.
b. Lower peak inspiratory pressures help alleviate this problem.
c. Rupturing of blebs or bullae may result from a strong cough effort during the treatment. These patients must be monitored closely.
6. Cardiac insufficiency
a. Patients with decreased blood pressure, decreased cardiac output, or other such cardiac problems must be monitored closely for further cardiac side effects.
b. Further cardiac problems may result from
(1) Positive pressure causing decreased venous return
(2) Cardiac side effects of bronchodilating agents
7. COPD patient with air trapping
a. IPPB may lead to an increase in air trapping in these patients, causing an inadvertent PEEP, which may decrease cardiac output.
b. These patients already have hyperinflated lungs, and IPPB may worsen this condition.
8. Uncooperative patient
a. Patient must be cooperative for treatment to be effective.
b. Alternative therapy should be considered.

VI. POSITIVE EFFECTS OF IPPB IN THE TREATMENT OF PULMONARY EDEMA

A. Decreases venous return.
B. Increases VT to improve ventilation and oxygenation, which results in improved cardiac activity.
C. Improves oxygenation by increasing the diameter of the fluid-filled alveoli so that more surface area is available for gas exchange.
D. Delivers aerosolized ethanol (40% to 50% concentration in water), which results in the dissipation of foamy edematous fluid.

image Exam Note

Ethanol is seldom used clinically, but questions regarding its use may appear on the exam.

E. Increases oxygenation because the treatment is delivered with 100% oxygen.

VII. PROPER ADMINISTRATION OF IPPB

A. Assemble all equipment and check machine for leaks.
B. Affirm physician order: If there is a question about the order, such as medication dosage, contact the physician for clarification.
C. Briefly review the patient chart for the following
1. Last treatment given
2. Latest chest film interpretation
3. Latest ABG results
D. Wash hands.
E. Identify patient by wristband, introduce yourself, and explain the reasons for administering the treatment.
F. Connect the circuit to the IPPB unit and plug into gas source.
G. Place medications in nebulizer.
H. Auscultate breath sounds to locate problem areas (e.g., atelectasis, secretions).
I. Determine heart rate and respiratory rate.
J. Assist the patient to an upright position because this allows better ventilation.
K. Place the mouthpiece in the patient’s mouth and encourage the patient to keep his or her lips sealed tight and to breathe only through the mouth. (Use nose clips if the patient has difficulty.)
L. Instruct the patient to “sip” on the mouthpiece and allow the machine to fill the lungs until it cycles off. Tell the patient to hold his or her breath for a count of three before exhaling to better distribute medications and improve gas exchange. Tell the patient to pause before the next breath.
M. Set machine variables.
1. Inspiratory pressure: Start at lower than the desired pressure and gradually increase as treatment continues. (Increase the flow rate as pressure is increased to maintain the same inspiratory time.)
2. Flow rate
3. Nebulization
4. Sensitivity
N. Check vital signs halfway through the treatment. Allow a brief rest period.

image Exam Note

If the pulse rate increases more than 20 beats/min, stop treatment and notify the physician.

O. After 10 min or when the medication is completely nebulized, encourage the patient to cough.
P. Check vital signs again.
Q. Encourage the patient to cough periodically for the next 30 min to 2 h as the effect of the medications peaks.
R. Wash hands.
S. Record vital signs, tolerance to treatment, cough effort, sputum characteristics (i.e., color, amount, consistency), and measured exhaled IPPB VT in the patient’s chart.

VIII. CHARACTERISTICS OF SPECIFIC IPPB UNITS

How ippb machines operate are not generally covered on the exams. The following information is stated to gain a better understanding of the machines which could indirectly help with specific ippb questions.

A. Bird Mark 7

image

FIGURE 7-1

1. The Bird Mark 7 is a pneumatically powered and controlled ventilator. It is designed to operate with oxygen or air at a pressure of 50 psig. It is pressure-cycled, and its settings include a patient cycle, a time cycle, or a manual cycle.
2. Gas flow through the Bird Mark 7
a. Gas enters the unit from the 50-psig wall outlet through a brass filter.
b. The first control that the gas travels to is the flow rate control, which is a simple needle valve.
c. From the flow rate control, gas travels to the ceramic switch, which is positioned between the ambient chamber and pressure chamber of the unit. Depending on the position of the ceramic switch, flow is either blocked or is allowed to pass through.
d. For the patient to trigger the unit into inspiration, he or she must create enough negative pressure to separate a metal clutch plate from a magnet in the ambient chamber. This pulls the ceramic switch to the right, allowing gas flow to continue through the unit.
e. As gas flows past the ceramic switch, the gas splits: part of the flow supplies the expiratory drive line and nebulizer and the other part flows into the ambient chamber through a Venturi tube, which entrains ambient air. This increases flow and decreases the percentage of O2.
f. The “mixed” gas then travels through the Venturi gate and into the pressure chamber, where the patient circuit is connected and flow continues on to the patient. The gate contains a spring with a tension of 2 cm H2O that closes toward the end of inspiration. This blocks “mixed” gas from entering the pressure chamber, which results in only source gas (O2) going to the chamber and the FiO2 increasing to approximately 90% during the last portion of the inspiratory cycle.
g. Inspiration ends as gas in the patient’s lungs builds up to a pressure that overcomes the magnetic force between another magnet and metal clutch plate located in the pressure chamber.
3. Bird Mark 7 Controls
a. Flow control
(1) The scale is made up of reference numbers and does not represent liters per minute.
(2) Flow rates available are 0 to 80 L/min on air mix and 0 to 50 L/min on 100% O2.
(3) To decrease inspiratory time, increase flow rate; to increase inspiratory time, decrease flow rate.
(4) Flow wave patterns on Bird Mark 7

image

FIGURE 7-2

(a) Square wave (constant flow) on 100% O2
(b) Tapered wave (decelerating flow) on air mix
b. Air mix control
(1) When pulled out, it allows flow into the ambient chamber and then through a Venturi tube, which results in air entrainment and delivery of 40% to 90% O2.
(2) When pushed in, it blocks flow to the ambient chamber, not allowing for air entrainment, and therefore delivering 100% O2.
(3) The air-mix setting creates a higher flow rate; 100% O2 creates a lower flow rate.
c. Inspiratory pressure control
(1) Adjusts the position of the magnet in the pressure chamber closer to or farther away from the metal clutch plate.
(2) The closer the magnet is to the metal clutch plate, the higher the inspiratory pressure required to move the clutch plate and to end inspiration.
(3) Increasing pressure increases VT; decreasing pressure decreases VT
d. Sensitivity control
(1) Adjusts the position of the magnet in the ambient chamber closer to or farther away from the metal clutch plate.
(2) The closer the magnet is to the metal clutch plate, the more negative pressure is required by the patient to cycle the machine into inspiration (and vice versa).
(3) The position of the magnet should be such that the patient is required to generate a pressure of no more than −2 cm H2O to initiate inspiration.
e. Expiratory timing device
(1) This is a needle valve that controls a leak from the expiratory timer cartridge and is used to automatically cycle the unit.
(2) It should always be turned off while administering IPPB, or the unit will self-cycle.
f. Hand timer rod
(1) Located on the left side of the unit (ambient pressure side) and used to manually cycle the unit off or on.
B. Bennett PR-2 Ventilator

image

FIGURE 7-3

1. The PR-2 is a pneumatically powered, pressure-limited ventilator that may be patient- or time-triggered and flow- or time-cycled.
2. Diluter regulator
a. This is an adjustable reducing valve that controls the pressure generated in the patient circuit.
b. It is adjustable from 0 to 50 cm H2O.
3. Bennett valve
a. This is the heart of the PR-2. Gas comes from the diluter regulator to this valve and rotates it to the opened position. Gas then travels on to the patient via the circuit. The valve also opens in response to the patient’s negative pressure.
b. As inspiratory pressure increases, the flow begins to decrease (resulting from a decrease in the pressure gradient), rotating the Bennett valve to the closed position, stopping gas flow, and ending inspiration.
4. PR-2 controls
a. Inspiratory pressure control
(1) Adjusts the peak inspiratory pressure
(2) Adjustable from approximately 0 to 50 cm H2O
b. Dilution control
(1) When the dilution control knob is pushed in, air entrainment is allowed and the percentage of delivered O2 varies from 40% to 90%.
(2) When the dilution control knob is pulled out, no air entrainment is allowed and 100% O2 is delivered.
c. Terminal flow control
(1) Adds an additional 12 to 15 L/min of flow below the Bennett valve to help cycle the unit off in case leaks are present.
(2) This added flow goes to a Venturi tube, which decreases the percentage of O2 (especially important if the patient is receiving 100% O2).
d. Sensitivity control
(1) Turning this control counterclockwise increases the sensitivity, making it easier for the patient to cycle the unit into inspiration (and vice versa).
(2) When the sensitivity control is turned off, the unit is factory-set for the patient to initiate inspiration by generating a pressure of −0.5 cm H2O.
e. Peak flow control
(1) In its fully open position (all the way to the left), the flow rate is approximately 90 to 100 L/min with air dilution and 20 cm H2O of pressure.
(2) In the fully closed position (all the way to the right), the flow is approximately 15 L/min.
f. Nebulization control
(1) Separate controls for inspiratory or expiratory nebulization.
(2) Gas that is sent to the nebulizer is source gas (100% O2 if the unit is plugged into an O2 outlet); therefore, the percentage of O2 increases when the nebulizer is used for medications.
g. Rate control and expiratory time
(1) Used to automatically trigger the unit on.
(2) Turning the rate control to the right sets the rate (adjustable from 0 to 50 breaths/min).
(3) The expiratory time control lengthens the expiratory time.
(4) These controls should be turned off during the administration of IPPB; otherwise, the unit self-cycles.
C. Bennett AP-5Recently the exam has asked questions regarding this machine as the one to be used in the home setting because it runs on electricity.

image

FIGURE 7-4

1. This IPPB unit is electrically powered, and inspiratory flow is powered by a compressor.
2. Compressed gas is not necessary for the functioning of this IPPB machine; therefore, it is a popular model for use in the home.
3. It is pressure-limited and patient-cycled and has a continuous flow for nebulization that comes from the compressor to the jet of the nebulizer.
4. Maximum peak pressure is approximately 30 cm H2O.

IX. FACTORS TO CONSIDER WHEN USING A PRESSURE-LIMITED IPPB MACHINE

A. Effects on delivered VT
1. Increased airway resistance results in decreased VT.
2. Decreased airway resistance results in increased VT.
3. Increased lung compliance results in increased VT.
4. Decreased lung compliance results in decreased VT.
5. Increased inspiratory pressure results in increased VT.
6. Decreased inspiratory pressure results in decreased VT.
7. Increased flow results in decreased VT.
8. Decreased flow results in increased VT.
B. Effects on inspiratory time
1. Increased flow results in decreased inspiratory time.
2. Decreased flow results in increased inspiratory time.
3. Increased lung compliance results in increased inspiratory time.
4. Decreased lung compliance results in decreased inspiratory time.
5. Increased airway resistance results in decreased inspiratory time.
6. Decreased airway resistance results in increased inspiratory time.

X. PROBLEMS WITH IPPB AND CORRECTIVE ACTIONS

A. The patient is having difficulty cycling the IPPB machine into the inspiratory phase. Corrective actions
1. Adjust the sensitivity so that the patient has to generate a pressure of −0.5 to −2 cm H2O to start inspiration.
2. Make sure the machine is plugged into the wall gas outlet.
3. Ensure machine tubing connections are all tight.
4. Ensure the patient has lips sealed tightly around the mouthpiece or, if a mask is used, that there are no leaks around it.
5. If the Bird Mark 7 is used, ensure the flow control is turned on.
B. The patient complains of dizziness and tingling in the extremities during the treatment but has no appreciable increase in heart rate. Corrective action: Instruct the patient to breathe slower and to pause longer between breaths.
C. The patient’s heart rate increases more than 20 beats/min during treatment. Corrective action: Stop treatment immediately and notify the physician. This is most likely the result of the nebulized bronchodilating agent stimulating the heart.
D. The patient cannot cycle the IPPB machine off. Corrective actions
1. Tighten all tubing connections.
2. Ensure that there are no leaks around the mouthpiece or mask.
3. Ensure that the ET tube or tracheostomy-tube cuff is inflated adequately.
4. If using the Bennett PR-2, check to make sure that the Bennett valve is not stuck.
5. If using the PR-2, turn on the terminal flow control to help compensate for leaks.
6. Check the expiratory valve function.
E. As the patient inhales, there is no nebulization of the medication. Corrective actions
1. Ensure that the capillary tube of the nebulizer is connected.
2. If using the Bennett PR-2, ensure that the nebulization control is turned on.
3. Ensure that the nebulizer drive line is connected.
4. Ensure that there is medication in the nebulizer.
5. Ensure that the nebulizer is positioned in an upright position.
F. During inspiration, the manometer needle stays in the negative area for the first half of the breath and then rises to the positive area during the last half. Corrective action: Increase the machine flow rate.
G. The IPPB machine repeatedly cycles on shortly after the patient has begun the expiratory phase. Corrective actions
1. Decrease the machine sensitivity.
2. If using the Bird Mark 7, ensure that the expiratory time for apnea control is turned off.
3. If using the Bennett PR-2, ensure that the rate control is turned off.

XI. INCENTIVE SPIROMETRY (SUSTAINED MAXIMAL INSPIRATORY THERAPY)

CRT Exam Content Matrix: IIA13, IIID1a-b, IIIF2b

RRT Exam Content Matrix: IIID1, IIIF2b

A. Goals of Incentive Spirometry
1. To prevent postoperative atelectasis.
2. To treat preexisting atelectasis.
3. To improve the cough mechanism.
4. To maintain the airway during the preoperative period.
a. Strengthens lung muscles before surgery
b. Improves mobilization of secretions
5. To provide early detection of atelectasis or pneumonia by observing decreasing inspiratory capacity levels.
B. Hazards of Incentive Spirometry
1. Hyperventilation.
2. Pneumothorax (unlikely but higher incidence in COPD patients).
3. Increased intrapleural pressure and stimulation of the vagal reflex, causing bradycardia if the sustained maximal inspiratory pause is performed against a closed glottis (Valsalva maneuver).
C. Requirements for Effective Incentive Spirometry
1. Cooperative patient.
2. Motivated patient.
3. Patient’s respiratory rate should be less than 25 breaths/min.
4. Patient’s vital capacity (VC) should be more than 10 mL/kg of body weight; IPPB may be indicated if VC is less than 10 mL/kg.
D. Steps in Performing Incentive Spirometry
1. Explain in understandable terms the importance of deep breathing and coughing. (Avoid terms such as atelectasis, inspiratory capacity, and the like; rather, use terms that the average nonmedical person can easily understand.)
2. Determine the patient’s initial inspiratory goal. A good starting point is twice the patient’s tidal volume. Some incentive spirometers come with a nomogram based on the patient’s gender, age, and height to determine the normal inspiratory capacity.
3. Place the patient in a semi-Fowler or Fowler position. Always place the patient in a sitting position to allow for a better inspiratory effort.
4. Instruct the postoperative patient to splint the incision site when inhaling. Assist the patient when necessary.
5. Then instruct the patient in the following steps for therapy
a. Hold the spirometer in an upright position or place on a flat surface.
b. Place the mouthpiece in the mouth and keep lips sealed tight.
c. After a normal exhalation, inhale slowly and as deeply as possible (inspiratory capacity). Hold the breath for 3 to 5 s, then remove the mouthpiece and exhale normally.
d. Rest and breathe normally for approximately 30 s.
e. Repeat the maneuver 8 to 10 times per waking hour.
6. Document the procedure and the patient response to therapy in the patient chart.
7. Evaluate the patient periodically to ensure that a proper breathing technique is being used.
E. Incentive Spirometry Devices

image

FIGURE 7-5

POSTCHAPTER STUDY QUESTIONS

1. List five physiologic effects of IPPB.

2. List seven indications for IPPB.

3. List eight hazards of IPPB.

4. List two absolute contraindications to IPPB.

5. The pulse rate must not exceed how many beats/min before the treatment must be terminated?

6. What effect does an increased airway resistance have on delivered VT on a pressure-limited IPPB machine?

7. What effect does an increased lung compliance have on the delivered VT on a pressure-limited IPPB machine?

8. How does a decreased lung compliance affect inspiratory time?

9. List ways to help correct a situation in which the patient has difficulty cycling the IPPB machine into the expiratory phase.

10. How should an IPPB treatment be modified for a patient with a closed head injury?

11. Incentive spirometry is indicated if a patient can obtain a vital capacity of what level?

12. What is another term used for incentive spirometry?

13. List three requirements necessary for incentive spirometry to be effective.

See answers at the back of the text.

BIBLIOGRAPHY

Cairo JM, Pilbeam S. Mosby’s respiratory care equipment, ed 8. St Louis: Mosby; 2009.

Hess D, Respiratory care principles and practice, et al., ed 1, Philadelphia, Saunders, 2002.

Wilkins RL, Stoller JK, Kacmarek R. Egan’s fundamentals of respiratory care, ed 9. St Louis: Mosby; 2009.

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