Hyperinflation Therapy

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7 Hyperinflation Therapy

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and the WRE, it will be shown simply as: (Code: …). If an item is testable only on the ELE, it will be shown as: (ELE code: …). If an item is testable only on the WRE, it will be shown as: (WRE code: …).

Following each item’s code will be the difficulty level of the questions on that item on the ELE and WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall [R] level questions typically expect the exam taker to recall factual information. Application [Ap] level questions are harder because the exam taker may have to apply factual information to a clinical situation. Analysis [An] level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision.

Note 2: A review of the most recent Entry Level Examinations (ELE) has shown that an average of two questions (1% of the exam) will cover hyperinflation therapy. A review of the most recent Written Registry Examinations (WRE) has shown that an average of two questions (out of 100), or 2% of the exam, will cover hyperinflation therapy.

MODULE A

Perform coughing and deep-breathing procedures with the patient to help make breathing more effective.

1. Instruct the patient in deep-breathing techniques (Code: IIID1a) [Difficulty: ELE: R, Ap; WRE: An]

Explain to the patient that taking in deep breaths keeps the small air sacs in the lungs inflated and healthy. Deep breathing and coughing are indicated in patients with atelectasis, pulmonary infiltrates, or pneumonia. These exercises should help to increase secretions. It is especially important to use deep breathing and coughing to prevent or limit atelectasis and pneumonia in patients who have just had abdominal surgery such as cholecystectomy or splenectomy. Ideally, the patient is taught these techniques before surgery is performed. If not, teach them the following postoperatively:

1. To decrease the pain, minimize traction or tension on the incision by placing your or the patient’s hands on both sides of the incision. Alternatively, the practitioner or the patient can hold a pillow against the incision.
2. Instruct the patient to breathe two or three times in through the nose and out through the mouth.
3. Instruct the patient to take in as deep a breath as possible and to perform a normal cough.
4. If the patient cannot cough normally because of pain, a serial cough can be performed.

Teach the following cough techniques to the patient with obstructive airways disease:

1. Avoid an ineffective, shallow, hacking cough.
2. Position the patient in a sitting position, bent slightly forward, with feet on the floor or supported. The patient who must lie in bed can be positioned on the preferred side with the legs flexed at the knees and hips.
3. Instruct the patient to perform a mid-inspiratory cough.

a. Breathe two or three times in through the nose and out through the mouth.
b. Breathe in to a comfortable volume larger than the tidal volume (VT), but not as deeply as possible.
c. Briefly hold the breath.
d. Cough hard, or perform a serial cough at relatively low flows. This should help to raise secretions without causing airway collapse.
e. Squeezing the knees and thighs together at the instant of coughing helps to increase the airflow and volume.

Coaching is important because patients in pain or who are suffering from chronic lung disease tend to be uncooperative and to not try hard. Give positive reinforcement when the patient does well. Correct any problems that the patient is having in trying to follow the instructions. Demonstrations often are helpful, so the patient can copy a good example.

2. Instruct the patient in inspiratory muscle training techniques (ELE code: IIID1b) [Difficulty: R, Ap]

Initially, teach the following steps to patients with obstructive airways diseases:

1. Have the patient lie in a comfortable supine position; knees can be flexed.
2. Instruct the patient to relax physically as much as possible, especially the shoulders.
3. Use soothing music, meditation, or other techniques for mental relaxation.
4. Instruct the patient to concentrate on breathing more slowly.
5. Emphasize pursed-lip breathing, wherein the patient with relaxed abdominal muscles breathes in slowly through the nose and out slowly through pursed (slightly opened) lips. Breathing with pursed lips keeps some backpressure on the airways so they stay open longer. The technique helps to improve gas exchange so the patient experiences less dyspnea.

After these first steps have been mastered, teach the following steps to patients with obstructive airways diseases:

1. The practitioner places his or her hands and the patient’s hands gently over the area(s) where the patient is to concentrate the breathing effort. Usually, this is the abdominal area just below the sternum. This encourages the patient to use the diaphragm more effectively and to strengthen it. With diaphragmatic breathing, the hands move out during an inspiration.
2. The same hands-on technique can be used to aid in segmental breathing over an area that is underventilated or that has atelectasis.
3. Breathing in against an obstruction can also increase the strength and endurance of inspiratory muscles. A variety of devices are available. One type of device is a mouthpiece with selectable, variably sized openings at the other end (Figure 7-1). The patient breathes in through the largest opening and progresses to smaller openings as tolerated.
image

Figure 7-1 PFLEX inspiratory muscle trainer. The body of the device features a dial selector with inspiratory holes. The holes range from the 1 setting (largest opening) to the 6 setting (smallest opening). A one-way valve allows the patient to expire. The mouthpiece can be attached directly to the body, or a monitoring/oxygen adapter can be added between them. This adapter allows oxygen to be added to meet the patient’s needs. An inspiratory force meter also can be added to determine the amount of negative pressure the patient is generating at each of the inspiratory hole settings.

(Courtesy of Philips Respironics, Murrysville, PA.)

Increasing the strength and endurance of inspiratory muscles usually requires a training program similar to the following:

1. Plug the nose with nose clips.
2. Inspire a normal tidal volume (VT) at a rate of 12 to 15 breaths/min through the largest opening.
3. Continue for 10 to 15 minutes per day for a total of 3 to 5 times/wk in the first week. If the patient notices shortness of breath, a noticeably increased pulse rate, or increased fatigue, the exercise should be stopped until the symptoms are gone. Resume the exercise when the patient is comfortable again.
4. Gradually increase the duration to about 30 minutes per session or two 15-minute sessions per day.
5. When this schedule can be tolerated easily 3 times/wk, switch to the next smallest hole.
6. Repeat steps 1 to 5 as tolerated. The most beneficial exercise is tiring but not exhausting. The device may be adjusted to the next larger hole setting if the patient becomes too tired. The whole process usually takes 4 to 6 weeks before positive results are seen.
7. A maintenance program necessitates that exercise be done every other day.

MODULE B

Incentive spirometry

1. Instruct the patient in incentive spirometry techniques (Code: IIID1a) [Difficulty: ELE: R, Ap; WRE: An]

Incentive spirometry (IS) is a technique whereby a patient is encouraged to breathe deeply by seeing his or her inhaled volume on the spirometry device. The patient receives positive feedback by seeing that the volume gradually increases as his or her condition improves. IS is indicated in any patient who has developed or is likely to develop atelectasis and can perform the procedure. Clinical situations and individuals in which atelectasis is likely to be seen include postoperative thoracic or upper abdominal surgery, the aged, the obese, inadequate sigh, cardiopulmonary disease, and quadriplegia and/or dysfunctional hemidiaphragm(s).

Exam Hint 7-1 (ELE, WRE)

Remember that incentive spirometry is the preferred treatment choice for atelectasis in patients who can perform it properly.

Because the goal of IS is to prevent or treat atelectasis, the patient should inhale a near-normal inspiratory capacity (IC). The patient can benefit more by holding the IC for several seconds, which is referred to as sustained maximal inspiration (SMI). Before the operation, the cooperative surgical patient should have the IC measured at the bedside or calculated from a pulmonary function test in which vital capacity (VC) is measured (review Chapter 4 for IC information). The IC is measured again postoperatively.

Before you start to provide instruction, make sure that the patient is alert and cooperative enough to follow instructions. The patient’s respiratory rate should be less than 25 breaths/min if the procedure is to be performed properly. Use the following steps in teaching IS:

1. Have the patient sit in semi-Fowler’s position, on the edge of the bed, or up in a chair.
2. Set an initial goal of twice the patient’s measured bedside VT.
3. Tell the patient the purpose of the treatment and how to perform it properly.
4. Simulate the procedure for the patient.
5. Put the unit within easy reach, and keep it upright.
6. Have the patient exhale normally (to functional residual capacity), seal the lips around the mouthpiece, and inspire maximally through the unit. The patient must inspire in a slow, controlled effort.
7. Have the patient hold the IC for at least 3 seconds but no longer than 15 seconds before exhaling (the SMI).
8. Proceed to extend the patient’s goal as tolerated and indicated earlier.
9. The patient should perform the deep breath at least 10 times/hr while awake. With normal breathing, a rest period should take place after each large breath.

Monitor your patient’s progress in the following ways:

1. If the patient cannot meet the initial goal, reconsider whether this is the best form of treatment. Intermittent positive-pressure breathing (IPPB) might be a better choice for providing a deep breath.
2. Stop the treatment temporarily if the patient has signs of hyperventilation, such as dizziness or tingling of the fingertips. A few minutes of normal breathing should result in a normal feeling again. Have the patient take longer rest periods between maximal breaths.
3. Stop the treatment if the patient complains of acute chest pain. It is possible to cause pulmonary barotrauma by breathing in as deeply as possible. Evaluate the patient’s pulmonary condition and call the physician if indicated.

2. Increase or decrease the patient’s incentive spirometry goal (Code: IIIF2b) [Difficulty: ELE: R, Ap; WRE: An]

See Table 7-1 for IS guidelines. The following guidelines are also suggested:

1. Set the initial IC goal at twice the VT.
2. Increase the goal in 200-mL increments as the patient tolerates.
3. Set a final IC goal of greater than 12 mL/kg of ideal body weight, or set a forced vital capacity (FVC) goal of greater than 15 mL/kg of ideal body weight.
4. A normal person should have an IC of about 75% of his or her FVC. For example, a predicted FVC of 5.166 L was calculated for a male patient in Chapter 4. His predicted IC would be calculated as 5.166 L × 0.75 = 3.875 L. However, because of natural variations in people, he might inhale only 80% of this (3.1 L) and still be considered within normal limits. Use this as a guideline for anticipating a patient’s maximum IC, and do not expect your patient to inhale a greater IC than is physically possible.

TABLE 7-1 Guidelines for the Use of Incentive Spirometry

Postoperative Bedside Spirometry Treatment Modality
IC >80% of the preoperative value No treatment needed unless radiographic or clinical evidence of atelectasis exists.
IC at least 33% of the preoperative value or VC of at least 10 mL/kg IS is indicated.
IC <33% of the preoperative value or VC <10 mL/kg IPPB is indicated.

IC, Inspiratory capacity; IPPB, intermittent positive-pressure breathing; IS, incentive spirometry; VC, vital capacity.

Consider increasing the IS goal if the patient is easily able to reach the set goal, or if the patient’s breath sounds are diminished in the bases. Consider decreasing the IS goal if the patient cannot reach the set goal because it is too large, if the patient is frustrated and discouraged at his or her inability to reach the set goal, or if excessive surgical site pain prevents the patient from reaching the set goal.

MODULE C

Incentive spirometry equipment

1. Manipulate incentive spirometry equipment by order or protocol (ELE code: IIA13) [Difficulty: R, Ap, An]

2. Get the necessary equipment, put it together, and make sure that it works properly

Two basic types of IS equipment exist: flow displacement and volume displacement units.

a. Flow displacement

With flow displacement units, patients breathe in a flow great enough to raise one or more plastic balls in calibrated cylinders (Figure 7-2). The patient is encouraged to try to keep the ball (or balls) suspended by breathing in more deeply. Encourage the patient to breathe in slowly to suspend the balls for as long as possible. Have the patient watch as the balls are held up by the inspired breath to provide positive reinforcement for doing a good job. The patient is not helped by breathing in a fast, short breath and having the balls pop up and down. Volume is calculated by multiplying the flow per second needed to suspend the balls by the number of seconds that the balls are suspended. For example, 600 cc/sec × 2 sec = 1200 cc IC. Assemble the device by attaching the flow tube to the unit and the mouthpiece to the flow tube.

image

Figure 7-2 Triflo II incentive deep-breathing exerciser.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

b. Volume displacement units

With volume displacement units, patients breathe in a preset volume goal from the reservoir bellows (Figure 7-3). Many of these units have a whistle built into them to warn if the breath is too fast. Patients who cannot generate enough inspiratory flow to use a flow displacement unit should use a volume displacement unit instead.

image

Figure 7-3 Volume incentive breathing exerciser.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

Some units also have a small built-in leak so the patient must continue inspiring to keep the bellows suspended. Have the patient watch as the bellows is suspended for positive reinforcement for doing a good job. Volume is marked on the bellows container. If the unit has a built-in leak, multiply the volume inspired by the time the bellows is suspended. For example:

image

Assemble the device by attaching the flow tube to the unit and the mouthpiece to the flow tube.

3. Troubleshoot any problems with the equipment

In either type of incentive spirometer, an obstruction to the flow tube or mouthpiece or a built-in leak in the calibrated cylinders stops airflow. With a flow displacement unit, no balls will rise despite the patient’s inspiratory effort. With a volume displacement unit, the bellows will not rise despite the patient’s inspiratory effort. Clearing the obstruction or sealing the leak allows either unit to work properly.

Exam Hint 7-2 (ELE)

The exam is likely to include one question that deals with selecting, adjusting, or troubleshooting IS equipment.

MODULE D

Respiratory care plan

1. Analyze the available information to determine the patient’s pathophysiologic state (Code: IIIH1) [Difficulty: ELE: R, Ap; WRE: An]

Review the information in Chapter 1 that deals with the interpretation of breath sounds and chest x-ray findings. As was discussed earlier, atelectasis is the primary problem that can be treated with IS.

2. Determine the appropriateness of the prescribed respiratory care plan and recommend modifications when indicated

a. Determine the appropriateness of the prescribed therapy and goals for the patient’s pathophysiologic state (Code: IIIH3) [Difficulty: ELE: R, Ap; WRE: An]

IS is the easiest and least expensive way to treat atelectasis if the patient can properly perform the procedure. See Table 7-1 for guidelines on the indications for IS or IPPB.

b. Review the planned therapy to establish the therapeutic plan (Code: IIIH2a) [Difficulty: ELE: R, Ap; WRE: An]

c. Recommend changes in the therapeutic plan when indicated (Code: IIIH4) [Difficulty: ELE: R, Ap; WRE: An]

The following should be considered when the patient’s response is evaluated:

• The opening of atelectatic areas would be signaled by the return of normal rather than diminished or absent breath sounds.
• Acute chest pain could be the result of a pneumothorax from barotrauma. A chest x-ray film would be needed to confirm or deny the presence of a pneumothorax. Stop the treatment if a pneumothorax is suspected.
• Be prepared to measure VT, VC, and IC to determine the patient’s goals and evaluate his or her progress.
• The patient may have an increase in sputum production if the deep-breathing exercises and IS open up atelectatic areas. The patient may have a more productive cough because of a greater VC.

d. Terminate the incentive spirometry treatment based on the patient’s response to therapy (Code: IIIF1) [Difficulty: ELE: R, Ap; WRE: An]

Be prepared to stop the current treatment if the patient is having an adverse reaction to it. Usually, incentive spirometry is a safe procedure. However, some patients will hyperventilate during the procedure and will feel dizzy or light-headed. If this happens, the patient should be told to stop the treatment for a few minutes. The dizziness should go away, and the patient should be able to resume the IS procedure. Direct the patient to continue to inhale deeply but at a slower rate. If the above treatment modifications do not prevent the adverse effects, be prepared to recommend to the physician that the treatment be discontinued.

e. Recommend discontinuing the incentive spirometry treatment based on the patient’s response to therapy (Code: IIIG1i) [Difficulty: ELE: R, Ap; WRE: An]

A treatment can be discontinued for one of three reasons. First, an adverse reaction to or complication of the treatment can lead to cessation of treatment. For example, stop the treatment if the patient has a serious problem, such as chest pain, that may be the result of a pneumothorax. Inform the physician if clinical evidence of this is noted. Treatment also may have to be stopped if the patient repeatedly hyperventilates during the IS procedure. Other reasons to terminate the treatment include inadequate pain control, exacerbation of bronchospasm, hypoxemia from removal of the patient’s oxygen mask, and fatigue. If these problems are corrected, it may be possible to begin IS treatment again.

Second, ineffective treatment may lead to treatment discontinuation. If the patient cannot perform a proper IS treatment (unconscious, physically unable to perform, inadequate inspiratory volume), another way to treat atelectasis should be found. This could include IPPB. (See Chapter 14 for the discussion.) The physician would order this change in therapy.

Third, if the patient has recovered and no longer needs treatment, treatment can be discontinued. As the postsurgical patient recovers, walks about, and performs proper coughing and deep-breathing exercises, any atelectasis will be corrected. In many cases, IS can be stopped within a week after surgery. The physician would order that incentive spirometry be discontinued.

Exam Hint 7-3 (ELE, WRE)

Understand the indications for IS versus those for IPPB. Be prepared to recommend a change in IS volume or to change from IS to IPPB.

3. Respiratory care protocols

a. Develop the hyperinflation therapy protocol (Code: IIIH6b) [Difficulty: ELE: R; WRE: Ap, An]

b. Apply the hyperinflation therapy protocol (Code: IIIH8) [Difficulty: ELE: R, Ap; WRE: An]

c. Explain planned therapy and goals to the patient in understandable (nonmedical) terms to achieve the best results from the treatment (Code: IIIA6) [Difficulty: ELE: R, Ap; WRE: An]

d. Monitor the outcome of the hyperinflation therapy protocol (Code: IIIH7b) [Difficulty: ELE: R, Ap; WRE: An]

e. Communicate the outcome of therapy and change the treatment based on the protocol (Code: IIIA5) [Difficulty: ELE: R, Ap; WRE: An]

Review Table 7-1 for guidelines on the use of incentive spirometry. These and the previous discussion on adjusting the IS goal can be used to develop and implement a protocol and evaluate its outcomes. It may be possible to use a simpler patient care plan such as cough and deep-breathing exercises with ambulation. Or, it may be necessary to switch to IPPB.

4. Record and evaluate the patient’s response to the treatment(s) or procedure(s) by doing the following:

a. Record and interpret the following: heart rate and rhythm, respiratory rate, blood pressure, body temperature, and pain level (Code: IIIA1b4) [Difficulty: ELE: R, Ap; WRE: An]

b. Record and interpret the patient’s breath sounds (Code: IIIA1b3) [Difficulty: ELE: R, Ap; WRE: An]

If incentive spirometry is effective, the patient’s breath sounds should improve. Areas of atelectasis, with diminished breath sounds, now should be heard as normal (vesicular).

c. Record and interpret the type of cough the patient has and the nature of the sputum (Code: IIIA1b3) [Difficulty: ELE: R, Ap; WRE: An]

If incentive spirometry is effective, the patient should be able to take in a deeper breath. This should result in a more effective cough and the ability to cough out secretions. Always note the nature of the patient’s secretions.

d. Recheck any math work and make note of incorrect data (Code: IIIA1b2) [Difficulty: ELE: R, Ap; WRE: An]

Errors made in charting must be corrected by drawing a single mark through the error and writing in the correct information. Some prefer that the error be clarified further by writing in “error” next to it and adding initials. Never erase or use any covering material over an error.

5. Communicate information relevant to coordinating patient care and discharge planning [e.g., scheduling, avoiding conflicts, sequencing therapies] (Code: IIIA2b) [Difficulty: ELE: R, Ap; WRE: An]

Common scheduling problems involve meal times and when the patient must go to the radiology or physical therapy department.

BIBLIOGRAPHY

American Association for Respiratory Care. Clinical practice guideline: incentive spirometry. Respir Care. 1991;36(12):1402.

Cairo JM. Lung expansion devices. In Cairo JM, Pilbeam SP, editors: Mosby’s respiratory care equipment, ed 8, St Louis: Mosby, 2009.

Douce FH. Incentive spirometry and other aids to lung inflation. In Barnes TA, editor: Core textbook of respiratory care practice, ed 2, St Louis: Mosby, 1994.

Eubanks DH, Bone RC. Comprehensive respiratory care, a learning system, ed 2. St Louis: Mosby, 1990.

Fink JB. Bronchial hygiene and lung expansion. In: Fink JB, Hunt GE, editors. Clinical practice in respiratory care. Philadelphia: Lippincott Williams & Wilkins, 1999.

Fink JB. Volume expansion therapy. In: Burton GG, Hodgkin JE, Ward JJ, editors. Respiratory care: A guide to clinical practice. Philadelphia: Lippincott-Raven, 1997.

Fink JB, Hess DR. Secretion clearance techniques. In: Hess DR, MacIntyre NR, Mishoe SC, editors. Respiratory care principles & practice. Philadelphia: WB Saunders, 2002.

Johnson NT, Pierson DJ. The spectrum of pulmonary atelectasis: pathophysiology, diagnosis, and therapy. Respir Care. 1986;31:1107.

Mang H, Obermayer A. Imposed work of breathing during sustained maximal inspiration: comparison of six incentive spirometers. Respir Care. 1989;34:1122.

Rutkowski JA. Hyperinflation therapy. In: Wyka KA, Mathews PJ, Clark WF, editors. Foundations of respiratory care. Albany: Delmar, 2002.

Scuderi J, Olsen GN. Respiratory therapy in the management of postoperative complications. Respir Care. 1989;34:281.

Shapiro BA, Kacmarek RM, Cane RD, et al. Clinical application of respiratory care, ed 4. St Louis: Mosby, 1991.

Wilkins RL. Lung expansion therapy. In Wilkins RL, Stoller JK, Kacmarek RM, editors: Egan’s fundamentals of respiratory care, ed 9, St Louis: Mosby, 2009.

Wojciechowski WV. Incentive spirometers, secretion evacuation devices, and inspiratory muscle training devices. In Barnes TA, editor: Core textbook of respiratory care practice, ed 2, St Louis: Mosby, 1994.

SELF-STUDY QUESTIONS FOR THE ENTRY LEVEL EXAM See page 588 for answers

1. Your patient is quite weak and is unable to raise the ball marker on a flow displacement–type incentive spirometer to her set goal. She is becoming discouraged. What would you recommend?

A. Have her continue trying.
B. Recommend that she be switched to IPPB.
C. Change her to a volume displacement–type spirometer.
D. Discontinue the treatment because it is not effective.

2. A 16-year-old postoperative appendectomy patient has clear breath sounds and normal vital signs. What would you recommend to prevent atelectasis?

A. CPAP at 5 cm H2O
B. PEP therapy
C. IPPB
D. IS

3. If pulmonary function results are not available, what initial IS goal should be set?

A. The IC measured at the bedside
B. The VC measured at the bedside
C. Three times the VT measured at the bedside
D. Twice the VT measured at the bedside

4. It is recommended that IS be performed how often while the patient is awake?

A. At least 5 times/hr
B. At least 10 times/hr
C. At least 20 times/hr
D. At least 10 times/day

5. Your patient has just performed several excellent IS efforts. She complains of tingling fingers and dizziness. Your response would be to

A. Have her continue with additional IS maneuvers.
B. Check her fingers and forehead for cyanosis.
C. Call her physician to cancel the treatment order.
D. Tell her to relax and breathe quietly until she feels normal again.

6. Your patient has a flow displacement type of IS device. She is attempting but is unable to inhale forcibly through it. What is the most likely problem?

A. The inspiratory tube is obstructed.
B. The patient is not really trying.
C. The flow resistance is set too high.
D. The bellows is in the locked-down position.

7. A patient’s IS device is a flow displacement type. With good coaching, he can raise a ball with 900 cc/sec of flow. He can keep it elevated for 1.5 sec. What is his IC?

A. 450 cc
B. 900 cc
C. 1350 cc
D. 1800 cc

8. Your patient has been using an inspiratory muscle–training device. He is currently on the third largest of six settings and has been breathing comfortably through it 4 days/wk over the past 2 weeks. What would you now recommend that he do?

A. Keep breathing through the same inspiratory hole.
B. Breathe through the smallest hole.
C. Breathe through the largest hole.
D. Breathe through the next smallest hole.

9. A patient with advanced COPD is anxious and is feeling short of breath after returning from a medical procedure. What should the respiratory therapist tell the patient to do?

A. Turn up the oxygen flow rate to his nasal cannula.
B. Inhale through his PFLEX inspiratory muscle trainer.
C. Use pursed-lip breathing.
D. Exhale through his Flutter valve unit.

10. A patient is recovering from a neuromuscular disease and the physician wishes to speed up the process of strengthening his inspiratory muscles. What technique should the respiratory therapist recommend?

A. PFLEX inspiratory muscle trainer
B. Maximal inspiratory pressure (MIP)
C. Maximal expiratory pressure (MEP)
D. Trendelenburg positioning

SELF-STUDY QUESTIONS FOR THE WRITTEN REGISTRY EXAM See page 613 for answers

1. A previously healthy 27-year-old female had an emergency appendectomy 2 days ago. After a few minutes of incentive spirometry, she complains of tingling in her fingers and feeling dizzy. What should the respiratory therapist do?

A. Stop the treatment and chart the patient’s complaint.
B. Have her inhale at a slower rate.
C. Reduce her IS volume goal.
D. Have her inhale a deeper volume.

2. You are the respiratory therapist assigned to teach a postoperative abdominal surgery patient about incentive spirometry. How would you explain the purpose of the treatment?

A. It will prevent bilateral basilar microatelectasis.
B. It will help the surgical wound heal faster.
C. It will treat pneumonia.
D. It will keep areas of the lungs from collapsing.

3. A 40-year-old cooperative female patient had her gallbladder removed 2 days ago. She is now slightly feverish and her chest x-ray shows signs of atelectasis in the right lower lobe. What should be the first treatment procedure to treat the problem?

A. Incentive spirometry
B. PEP therapy
C. Nasotracheal suctioning
D. IPPB therapy

4. As the lead respiratory therapist, you are in charge of developing an incentive spirometry protocol for an obese postoperative open heart surgery patient with bilateral atelectasis. All of the following could be outcome measures EXCEPT

A. Normal lung fields on chest x-ray
B. Increased arterial oxygen level
C. Increased cardiac output
D. Improved breath sounds

5. A 150-pound (70-kg) patient with a recent stroke has complications of atelectasis and bronchitis. His inspiratory capacity is measured at 40% of his predicted value. What therapy would be most appropriate initially?

A. Incentive spirometry with sustained maximal inspiration
B. IPPB therapy
C. Positive expiratory pressure therapy
D. Postural drainage with percussion and vibration

6. Your patient is using a flow displacement type of incentive spirometer at a rate of 20 times per minute. She is able to suspend the ball marker for 1 second at her targeted inspiratory capacity. How could the treatment be improved upon?

A. Increase her target volume by 500 mL.
B. Have her breathe at a slower rate and hold the volume longer.
C. Have her exhale more rapidly.
D. Lower her target volume by 100 mL and raise her respiratory rate to 25 times per minute.

7. You are called to evaluate a patient who has been using a volume displacement–type incentive spirometer for 2 days since her cholecystectomy procedure. She has been following a patient-directed protocol and is easily able to inspire the 1.5-liter goal set on the unit. What would you recommend?

A. Increase her goal to 3 liters.
B. Switch her to a flow displacement–type unit with a 1.5-liter goal.
C. Increase her volume goal to 2 liters.
D. Stop the protocol and begin IPPB treatments.

8. A patient with obstructive airways disease should be taught all of the following cough techniques EXCEPT

A. Take two to three breaths in and out before coughing.
B. Breathe in a volume larger than the VT but less than the VC.
C. Perform a normal cough.
D. Perform a midinspiratory cough.

9. IS is indicated when a patient’s postoperative IC is what percentage of the preoperative IC?

A. Between 30% and 50%
B. Between 50% and 80%
C. Between 80% and 90%
D. Greater than 90%

10. Your patient has an ideal body weight of 90 kg (200 lb). What would be his initial IC goal?

A. His VC
B. At least half of his VC
C. At least 1080 mL
D. At least 540 mL

11. If IS has been successful, which breath sounds can be heard in the areas where atelectasis was noted before treatment?

A. Bronchial
B. Absent
C. Normal vesicular
D. Tracheal

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