Intermittent Positive-Pressure Breathing

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14 Intermittent Positive-Pressure Breathing

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’s (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 simply be shown as: (Code: …). If an item is only testable on the ELE, it will be shown as: (ELE code: …). If an item is only testable 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 an average of 3 questions (out of 140), or 2% of the exam, that cover intermittent positive-pressure breathing (IPPB). A review of the most recent Written Registry Examinations (WRE) has shown an average of 2 questions (out of 100), or 2% of the exam, that cover IPPB. The Clinical Simulation Examination is comprehensive and may include everything that should be known by an advanced level respiratory therapist

MODULE A

Initiate and adjust intermittent positive-pressure breathing (IPPB) therapy to achieve adequate respiratory support (Code: IIID2a) [Difficulty: ELE: R, Ap; WRE: An]

1. Description

The Respiratory Care Committee of the American Thoracic Society published the following definition in its 1980 Guidelines for the Use of Intermittent Positive Pressure Breathing (IPPB): “‘IPPB treatments’ refers to the use of a pressure-limited respirator to deliver a gas with humidity and/or aerosol to a spontaneously breathing patient for periods of time that are generally no greater than 15 to 20 minutes each.”

A pressure-limited respirator may be powered by compressed gas or electricity. The patient’s tidal volume (VT) should be greater than normal when enhanced by IPPB. This greater-than-normal VT is caused by the use of positive pressure against the lungs. Pressure is also directed against the airways and, through contact with the airways and lungs, the entire chest. The patient’s exhalation is usually passive but can be slowed through modification of the exhalation valve.

Shapiro and associates (1991) list the following as the physiologic effects of IPPB:

a. Increased mean airway pressure

By definition of IPPB, the patient is receiving a positive airway pressure instead of generating a negative intrathoracic pressure to create the VT. Most authors recommend that patients with heart disease be monitored closely for the effects of increased mean airway pressure. Decreasing the normal return of venous blood to the heart, thereby decreasing the cardiac output, is possible. Shapiro and associates (1991) recommend an expiratory time that is long enough to allow for normal venous return before the next positive-pressure breath is given. The patient’s heart rate and blood pressure can be monitored to ensure that they stay in the normal range.

Pulmonary barotrauma is the second concern raised by the use of positive airway pressure. It is possible for patients with small airways disease to trap air in the alveoli. This can lead to the rupture of a bleb, thus causing a pneumothorax. Care must be taken with the patient with bullous emphysema to ensure that the VT is exhaled completely.

b. Increased tidal volume

The primary goal of IPPB is to increase the patient’s assisted VT to greater than the spontaneous VT. Indeed, if the spontaneous VT is greater than the assisted VT, IPPB is not needed for lung expansion.

c. Decreased work of breathing

A properly coached passive treatment with the controls set to meet the patient’s inspiratory needs causes a decrease in the work of breathing (WOB). This necessitates considerable skill on the part of the practitioner. Sensitivity, inspiratory flow, and peak pressure must be frequently adjusted to minimize the patient’s work. The patient must be asked if the control adjustments make it easier or harder to inhale. Failure to tailor the breathing treatment to the patient’s needs may actually increase the WOB.

d. Alteration of the inspiratory/expiratory ratio

Patients with high airway resistance or low lung compliance often change their breathing patterns to reduce the WOB (see Chapter 1). These new breathing patterns may lead to worsening of the patient’s condition. Alteration of normal ventilation and perfusion ratios in the lungs may worsen hypoxemia. Properly administered and coached IPPB can be used to adjust the inspiratory/expiratory (I:E) ratio to the benefit of the patient. The patient can be taught how to breathe in a more physiologically normal pattern.

2. Indications

The following indications and guidelines are listed in the American Association for Respiratory Care (AARC) Clinical Practice Guidelines (1991, 2003) on IPPB:

a. To treat atelectasis when other deep breathing methods are ineffective

Patients who are uncooperative, unconscious, or physically incapable of being coached in deep-breathing and coughing techniques or in performing incentive spirometry (IS) may be helped by IPPB. An inspiratory pause at the end of the IPPB breath helps to better distribute the gas to open areas of atelectasis. As has been discussed in Chapter 7, a patient would benefit from IPPB rather than IS if any of the following apply:

• Inspiratory capacity (IC) of less than 12 mL/kg
• Vital capacity (VC) of less than 15 mL/kg
• Postoperative IC less than 33% of the predicted value (predicted IC = 1/3 [i.e., 0.33] × 50 mL/kg of ideal body weight)

The AARC guidelines on IPPB list the following poor pulmonary function values as supporting the need for IPPB because the patient would have an ineffective cough:

• Vital capacity (VC) less than 70% of predicted or less than 10 mL/kg
• Forced expiratory volume in 1 second (FEV1) less than 65% of predicted
• Maximum voluntary ventilation (MVV) less than 50% of predicted

Exam Hint 14-1 (ELE)

It is important to understand the indications of IPPB versus incentive spirometry (IS) in the treatment of a patient with atelectasis. In general, IPPB would be indicated in a patient who could not properly perform IS.

b. To more effectively deliver aerosolized medications

If the patient cannot coordinate his or her breathing pattern to make use of a metered dose inhaler or handheld nebulizer, IPPB may be used. Examples of when IPPB is preferable include any situation in which the patient is unconscious, uncooperative, or physically incapable. These patients are physically unable to make effective use of simpler methods of lung inflation (incentive spirometry) or to take an aerosolized medication (metered dose inhaler or handheld nebulizer). Examples of these types of patients include the elderly, the chronically debilitated, patients with neuromuscular diseases, and patients with kyphoscoliosis. It may also be used to provide temporary support to home care patients.

c. To enhance the patient’s cough effort and sputum clearance

The combination of aerosolized saline, with or without a bronchodilator or mucolytic, and deeper tidal volumes may help the patient to cough more productively. The practitioner must stop the treatment periodically to coach the patient’s cough effort.

The following additional indications were listed in the Guidelines for the Use of Intermittent Positive Pressure Breathing (IPPB) published by the Respiratory Care Committee of the American Thoracic Society (1980).

d. To treat impending ventilatory failure as seen by an increased arterial carbon dioxide partial pressure (PaCO2)

It may be possible to delay or avoid intubation and mechanical ventilation in the deteriorating chronic obstructive pulmonary disease (COPD) patient. The patient is able to relax and reduce the work of breathing (WOB) during a passive IPPB treatment. It may be necessary to give IPPB for 5 to 10 minutes as often as every 30 minutes to 1 hour. The treatment should also be given with the intention of helping the patient’s cough and sputum clearance. (An alternative to frequent IPPB treatments is noninvasive positive-pressure ventilation. This is discussed in Chapter 15.)

e. To help manage the patient with acute pulmonary edema

IPPB can help in the management of this patient by temporarily increasing mean airway pressure. This reduces the venous return to the heart, which may reduce pulmonary edema. The IPPB procedure does not correct the underlying cardiac problem, which must be treated by other means.

f. To induce a sputum sample for culture and sensitivity or other diagnostic studies

Inducing a sputum sample by IPPB is indicated only if simpler methods have failed.

g. To deliver medications for special purposes when simpler methods are ineffective

IPPB should be used to deliver medication when simpler methods fail, for example, to deliver a local anesthetic such as lidocaine (Xylocaine) before a bronchoscopy procedure.

3. Contraindications

a. An untreated pneumothorax is listed by all authors and the AARC guidelines as an absolute contraindication. An increased intrathoracic pressure converts a simple pneumothorax into a tension pneumothorax. The consequences can be fatal. Once a chest tube has been inserted into the pleural space and a pleural drainage system set up, IPPB can be administered. There may be an increase in the air leak, but it will not be life-threatening.

The AARC guidelines list the following as relative contraindications. Any patient with one of the following contraindications should be evaluated carefully before a decision about the clinical use of IPPB is made:

b. Active hemoptysis

Expectoration of blood indicates that a tear has occurred in the airway or lung tissues. The IPPB treatment should be stopped if there is a large amount of hemoptysis. Certainly massive hemoptysis (defined as greater than 600 mL of blood expectorated in a 16-hour period) contraindicates IPPB.

c. Hemodynamic instability

d. Intracranial pressure greater than 15 mm Hg

e. Chest radiograph that shows a bleb

f. Tracheoesophageal fistula

g. Recent surgery on the esophagus, skull, face, or mouth

h. Untreated, active tuberculosis (hazard to the practitioner)

i. Nausea, air swallowing, or hiccups (singultation)

Exam Hint 14-2 (ELE, WRE)

Past examinations have included questions about the contraindications for IPPB, especially untreated pneumothorax or hemoptysis.

4. Hazards and precautions

The AARC guidelines list the following hazards and precautions for IPPB therapy:

a. Pneumothorax
b. Barotrauma
c. Increased airway resistance from a bronchospastic reaction to the positive pressure or an adverse reaction to a medication. This can result in alveolar overdistension and air trapping.
d. Hyperoxia when 100% oxygen is delivered to the patient. Some COPD patients who are hypercarbic and breathing on hypoxic drive may hypoventilate as a result.
e. Secretions that may become impacted when the inhaled gas is not humidified adequately
f. Nosocomial infection
g. Decreased venous return
h. Increased ventilation-to-perfusion mismatch. This may worsen any hypoxemia.
i. Hyperventilation
j. Psychologic dependence. This may be seen in the long-term home care patient who does not want to switch to another method of taking inhaled medications.
k. Hypocarbia
l. Hemoptysis
m. Gastric distension
n. Air trapping, auto-PEEP, or overdistended alveoli

5. Initiation of therapy

a. Steps in the basic procedure

1. Check for a complete and proper order specifying the patient, oxygen percentage, frequency of treatment, medication, and any special considerations.
2. Gather the necessary equipment, medication, and so on.
3. Assemble the equipment outside of the patient’s room.
4. Introduce yourself and the department you represent, and state your purpose to the patient.
5. Confirm the patient’s identity.
6. Have the patient sit up in bed or in a chair; an obese patient may stand.
7. Interview the patient.
8. Assess the patient’s vital signs.
9. Assess the patient’s breath sounds.
10. Prepare the IPPB unit for operation:

A. If the unit is electrical, plug it into a working outlet.
B. If the unit is pneumatic, plug it into either a compressed air or an oxygen outlet as ordered.
C. Set the following controls:

i. Set sensitivity at −1 cm H2O pressure.
ii. If a Bennett PR-2 is being used, set the nebulizer to run on inspiration only.
iii. Adjust the flow as necessary.
iv. Set the peak pressure at about 10 to 15 cm H2O.

D. Test the nebulizer by turning on the machine.
E. Cover the mouthpiece with a clean tissue to ensure that it cycles off at the preset pressure.

11. Instruct the patient to sip on the mouthpiece like a straw to turn the machine on. Have the patient relax and let the machine fill his or her lungs with air. The patient should hold his or her breath in for 2 to 3 seconds and exhale slowly.

b. Giving a passive treatment

Most authors describe the patient taking a passive treatment. In a passive treatment, the patient relaxes and lets the machine fill the lungs until the preset pressure is reached. As mentioned earlier, the patient is then told to hold in his or her breath before exhaling passively. This treatment is given with the intent of minimizing the patient’s WOB. As slow a flow rate as possible is used so that any nebulized medication is deposited deeply into the small airways and lungs.

c. Giving an active treatment

Several authors advocate having the patient take an active treatment in which he or she interacts with the IPPB machine to obtain as deep a breath as possible.

Welch and colleagues (1980) have found that the patient’s posttreatment IC is greatest when the practitioner (1) uses as high a peak pressure as the patient can tolerate and (2) coaches the patient to inhale as deeply as possible with the IPPB machine. They and others believe that this is the best way to treat or prevent atelectasis. Monitor the patient for signs of barotrauma/volutrauma.

6. Initial settings on the Bird Mark 7

The older version of the Mark 7 is used as the model respirator of the Bird series. The current Mark 8 has similar features. Other Bird units have slightly different controls and features. Refer to Figure 14-1 for the following:

• Adjust the air-mix knob to the desired gas mix.
• Sensitivity should be set so that the patient has to generate about −1 cm H2O pressure to cycle the unit on. Set the sensitivity control (on the left-hand side of the unit when facing it) to the reference number 15. This is at approximately the 2 o’clock position. Turning the control lever counterclockwise makes the unit more sensitive. Push in the hand timer rod to note that the unit cycles on easily.
• Flow should be set so that the patient feels comfortable with the inspiratory time. Set the flow rate knob so that the reference number 15 is at the 12 o’clock position; the off sign will be at the 8 o’clock position. Turning the flow rate knob counterclockwise increases the flow.
• Peak pressure should be set at about 10 to 15 cm H2O pressure. Set the pressure control (on the right-hand side of the unit when facing it) to the reference number 15. This is at approximately the 10 o’clock position. Turning the control lever more clockwise increases the peak pressure. Hold a clean tissue against the patient’s mouthpiece to see that the unit cycles off at the desired peak pressure.
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Figure 14-1 Controls and features of the Bird Mark 7 IPPB unit.

7. Initial settings on the Bennett PR-2

The PR-2 is used as the model respirator of the Bennett series. (Although the PR-2 is no longer being manufactured, many are still in clinical use.) Other Bennett units have slightly different controls and features. Refer to Figures 14-2 and 14-3 for the following:

• Adjust the air dilution knob to the desired gas mix.
• Sensitivity should be set so that the patient has to generate about −1 cm H2O pressure to cycle the unit on. Turning the control lever counterclockwise makes the unit more sensitive. Push up on the Bennett valve strut to note that the unit cycles on easily.
• Flow should be set so that the patient feels comfortable with the inspiratory time. The Bennett valve is designed to automatically open and close itself to allow the patient as much flow as desired. Set the peak flow control knob as counterclockwise as possible so that it is at the maximum setting. Turning the peak flow knob more clockwise will decrease the patient’s peak flow.
• Peak pressure should be set at about 10 to 15 cm H2O pressure. Dial the pressure control clockwise until the control pressure gauge shows the desired peak pressure. Hold a clean tissue against the patient’s mouthpiece to see that when the unit cycles off the system pressure gauge reads the same as the control pressure gauge.
• Turn the inspiration nebulization control counterclockwise for medication to be nebulized only during an inspiration. Some practitioners believe that the expiration nebulization control should be turned on slightly so that the mouthpiece and circuit dead space are filled with medication before the next breath. Others are opposed to this because it wastes medication when the patient stops the treatment.
• A small leak in the circuit, mouthpiece, or face mask can be overcome by adding some additional flow by turning on the terminal flow control. It is normally left off. Turn the control counterclockwise to add as much additional flow as necessary to overcome the leak.
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Figure 14-2 Front controls and features of the Bennett PR-II IPPB unit.

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Figure 14-3 Right-side controls and features of the Bennett PR-II IPPB unit.

Details on the design and control specifications for the various Bird and Bennett models can be found in the manufacturers’ literature and books on respiratory therapy equipment.

MODULE B

Independently modify IPPB based on the patient’s response to therapy (Code: IIIF2a) [Difficulty: ELE: R, Ap; WRE: An]

1. Change the patient-machine interface

a. Mouthpiece

A conscious, cooperative patient can take a treatment with a mouthpiece. He or she must be instructed to place the mouthpiece between the teeth (or gums) and seal the lips around it so that there is no leak. Instruct the patient to sip gently on it to turn on the IPPB machine. As long as the lips are sealed and there are no other leaks, the positive-pressure breath will stop when the preset pressure is reached. Nose clips are often helpful to prevent a leak through the nose as the patient is learning how to take the treatment. The nose clips can be removed after the patient has learned how to seal the nasopharynx with the soft palate.

A variety of mouthpieces are available. All share two common features: a raised edge so that the teeth do not slip off; and a 22-mm outer diameter (OD) connector end to insert into the IPPB circuit (Figure 14-4).

image

Figure 14-4 Universal IPPB mouthpiece with a tapered 22- to 18-mm machine connector.

b. Mouth seal (Bennett seal)

An unconscious, uncooperative, or aged patient who cannot seal his or her lips can be aided by placing a soft rubber seal around the mouthpiece. The practitioner gently holds the seal around the patient’s lips to seal the airway so that the patient can trigger the breath and cycle the machine off (Figure 14-5). Nose clips are also commonly needed.

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Figure 14-5 Top, Bennett or mouth flange seal. Bottom, IPPB mouthpiece inserted into the seal.

c. Face mask

The face mask can be used if the mouth seal does not provide an airtight seal. This might be because of the patient’s facial structure or lack of teeth. Mouth trauma, surgery, or lip sores are other reasons to use a face mask.

The mask should be clear and properly sized to fit comfortably over the patient’s nose and mouth. The practitioner should be able to get a seal with a minimum amount of hand pressure (Figure 14-6). The equipment connection opening in the mask has a 22-mm inner diameter (ID) so that it connects directly to the IPPB circuit. A 22-mm-OD male adapter and short length of aerosol tubing can be added for flexibility and patient comfort. The clear mask is important so that the practitioner can see whether the patient has vomited or has a large amount of secretions or saliva in his or her mouth. The mask should never be strapped to the patient’s face so that the practitioner can attend to another patient.

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Figure 14-6 Giving an IPPB treatment with the use of a face mask.

This is the least effective patient attachment device if the therapeutic goal is to deliver an aerosolized medication. Much of the medication drains out on the patient’s face or in the nasal passages if he or she is a nose breather.

d. Tracheostomy/endotracheal tube (elbow) adapter

The elbow adapter is designed to connect the patient’s tracheostomy or endotracheal tube to the IPPB circuit (or other respiratory care equipment). The IPPB end has a 22-mm-ID connector. The tracheostomy/endotracheal tube end has a 15-mm-ID connector (Figure 14-7). If the tube’s cuff has been deflated, it must be reinflated to seal the airway. An unsealed cuff results in an air leak, and the gas flow will not turn off.

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Figure 14-7 Giving an IPPB treatment with the use of a tracheostomy/endotracheal tube adapter.

2. Improve patient synchrony (Code: IIIG3a) [Difficulty: ELE: R, Ap; WRE: An]

Synchrony refers to the patient breathing in a coordinated pattern with the IPPB unit. Because the patient has to interact with the unit, some practice is required. The respiratory therapist must coach the patient to alter his or her breathing pattern as well as adjust the controls on the IPPB unit. Usually this involves adjusting sensitivity and flow.

a. Adjust the sensitivity

The sensitivity of the IPPB unit refers to how much effort or work the patient must perform to turn the unit on for a breath. Commonly, the sensitivity is set so that the patient has to generate a negative pressure of only about −1 cm H2O pressure to begin an inspiration. This can be seen by the needle deflecting into the negative range on the pressure manometer. Ask the patient whether the machine can be easily turned on to get a breath. The IPPB unit should not be set at a level so sensitive that it self-cycles.

The sensitivity range on the Bird series is −0.01 to −5 cm H2O. Turning the sensitivity/starting effort adjustment lever counterclockwise toward the smaller reference numbers makes the unit more sensitive. The sensitivity range on the Bennett series is −0.5 to −1 cm H2O. Turning the sensitivity control counterclockwise makes the unit easier to turn on.

b. Adjust the flow

The patient should initially feel comfortable with the flow rate and the inspiratory time. Ideally, the flow should result in a smooth, steady rise in the pressure up to the preset maximum pressure. Reduce the flow if the pressure rises too quickly. Increase the flow if the pressure wavers higher and lower; this indicates the patient is breathing in faster than the gas is being delivered. Ask the patient a simple question such as, “Is the breath coming too fast or too slow?” He or she can give you a short answer or even a hand gesture in response. As the treatment progresses, the practitioner may be able to adjust the flow to modify the patient’s breathing pattern to better achieve the therapeutic goal, for example:

• Anxious patients may initially need a fast flow. As they are coached to relax and become accustomed to the treatment, the practitioner should try to reduce the flow.
• Slower flows result in medications being deposited deeper into the lungs. This is important if the patient is having a bronchodilator, mucolytic, or antibiotic nebulized.
• Faster flows result in the deposition of medications in the upper airways. This is important if the patient is receiving racemic epinephrine for laryngeal edema or lidocaine for a local anesthetic of the upper airway before bronchoscopy.

Turning the inspiratory time/flow rate control counterclockwise increases the flow rate on the Bird series. Pulling the air-mix knob out from the center body increases the total flow by allowing room air to be entrained along with the source gas. Flow rate in the PR-II is determined by the patient’s inspiratory effort and the degree to which the Bennett valve is open. Flow can be decreased somewhat by turning the peak flow control clockwise. Flow is not affected by the position of the air dilution knob.

3. Adjust the fractional concentration of inspired oxygen

Compressed air or oxygen can power both the Bird and Bennett units. The patient’s condition determines the oxygen percentage administered. The physician may include the oxygen percentage in the treatment order. Some departments have oxygen protocols in their treatment procedure. Generally, compressed air (21% oxygen) should be used whenever the patient does not need supplemental oxygen.

A patient with COPD who is retaining carbon dioxide and breathing on hypoxic drive should also be given room air via the IPPB unit. The patient may be allowed to keep wearing a nasal cannula with oxygen during the treatment so that the blood oxygen level is kept normal. The unavailability of piped-in compressed air should not be an excuse to give a patient a high oxygen percentage when it may be harmful. IPPB can be given through a gas-powered unit driven by a compressed air cylinder or through an electrically powered unit.

Supplemental oxygen is given if either unit is powered by oxygen and the air-mix/air dilution knobs are set to dilute the source gas with room air. This is appropriate for patients who require supplemental oxygen and are not at risk of stopping their spontaneous ventilation. Most practitioners use this method of giving IPPB because piped oxygen is usually available in all patient rooms.

Pure oxygen should be given to the patient who is severely hypoxemic. Examples include acute pulmonary edema, respiratory failure, and carbon monoxide poisoning. The air-mix/air dilution knobs must be set so that only the source gas (oxygen) is delivered to the patient.

For varying oxygen percentages on the Mark 7, note the following guidelines:

• Pushing the air-mix knob into the center body results in pure source gas. This can be either air or oxygen.
• Pulling the air-mix knob out of the center body results in a dilution of the source gas with room air. If oxygen is the source gas, the room air will dilute the delivered gas to between 60% and 90% (or more) oxygen.

For varying oxygen percentages on the PR-II, note the following guidelines:

• Pulling the air dilution knob out of the body results in pure source gas. This can be either air or oxygen.
• Pushing the air dilution knob into the body results in a dilution of the source gas with room air. If oxygen is the source gas, the room air will dilute the delivered gas to between 40% and 80% oxygen.
• Turning on the terminal flow control results in the dilution of source gas with room air. This dilutes the final percentage if the source gas is oxygen.

4. Adjust the volume, pressure, or both

A review of the current respiratory care textbooks reveals that all authors agree that the basic goal of IPPB is to increase how deeply the patient inspires. Unfortunately, there is considerable difference about what inspiratory volume is being measured or by how much that breath should be increased for therapeutic goals to be achieved. The AARC has released the following guidelines on the subject:

• The AARC Clinical Practice Guideline (1991) on incentive spirometry: IPPB, rather than incentive spirometry, is indicated to treat atelectasis if (a) the patient’s IC is less than 33% of the preoperative value or (b) the patient’s VC is less than 10 mL/kg of ideal body weight.
• Therefore IPPB would only be indicated when the patient cannot perform incentive spirometry or is unable to reach the above clinical goals.
• The AARC Clinical Practice Guideline (1993) on IPPB: The tidal volume delivered during an IPPB-assisted breath should be at least 25% greater than the patient’s spontaneous breaths.

EXAMPLE

Calculate the minimum IPPB-delivered tidal volume goal for a 35-year-old 150-pound ideal body weight male with pneumonia. He has a spontaneous tidal volume of 500 mL. Steps in the calculation include:

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• The 2003 revision and update of the 1993 AARC Clinical Practice Guideline on IPPB states that the tidal volume delivered during an IPPB-assisted breath should be at least one third (0.33) of the patient’s predicted inspiratory capacity (IC).

EXAMPLE

Calculate the minimum IPPB-delivered tidal volume goal for a 35-year-old 150-pound ideal body weight male with pneumonia. He has a spontaneous tidal volume of 500 mL. Steps in the calculation include:

1. Convert the patient’s body weight in pounds (lb) to kilograms (kg):

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2. Calculate the patient’s predicted inspiratory capacity:

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3. Calculate the patient’s minimum IPPB-assisted tidal volume goal:

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Therefore the patient should receive an IPPB-assisted tidal volume of at least 1122 mL.

If the therapeutic goal is to prevent or treat atelectasis, having the patient inspire a deeper than spontaneous tidal volume breath should help. It seems reasonable to follow the AARC guidelines as clinical goals. Following the 2003 updated guidelines would provide the patient with a larger IPPB-assisted tidal volume. However, depending on the patient’s tolerance, it may be necessary to begin with a smaller initial tidal volume goal (1993 guidelines) and then increase the goal as tolerated.

Because all of the current IPPB units are pressure cycled, the only way to increase the inspired volume during a passive treatment is to increase the peak pressure. Coaching the patient during an active treatment results in a larger volume without the need for as great a peak pressure. Decrease the peak pressure if the patient complains of discomfort or cannot hold that much pressure without losing the lip seal.

5. Reduce auto-PEEP (Code: IIIG3l) [Difficulty: ELE: R, Ap; WRE: An]

Positive end-expiratory pressure (PEEP) is pressure added through a mechanical ventilator at the end of an exhalation to prevent the patient from exhaling fully. PEEP keeps the patient’s airway pressure greater than atmospheric (commonly given as the baseline pressure of zero). The clinical effect of PEEP is to increase a patient’s residual volume (RV) and functional residual capacity (FRC) to improve oxygenation. It is used when the patient has a clinical condition, such as atelectasis or acute respiratory distress syndrome (ARDS), that results in small lung volumes. Auto-PEEP is end-expiratory pressure in the lungs that cannot be seen on the IPPB unit’s (or ventilator’s) pressure manometer. Auto-PEEP is caused by air trapping because the patient does not have enough time to exhale completely. In other words, the patient starts another inspiration before the previous breath was completely exhaled. This problem is most commonly seen in patients with small airways disease such as asthma and COPD.

Over the course of an IPPB treatment, patients who have small airways disease can develop air trapping. This can lead to an increased RV and FRC, which is seen as auto-PEEP. This unwelcome lung overinflation increases the risk of pulmonary barotrauma. If auto-PEEP is known or suspected during an IPPB treatment, expiratory retard can be added to help ensure a complete exhalation. Adding expiratory retard to the treatment increases back-pressure on the airways and has the same effect as pursed-lip breathing. The clinical effect of adding some back-pressure on the smallest airways is to keep them open longer so that the more distal air can be exhaled.

The following two procedures can be used to help identify the presence of auto-PEEP:

1. Measure the exhaled volumes during the treatment and monitor the patient’s response to the inspired breath. If the patient is exhaling less tidal volume with succeeding breaths or the patient complains of fullness, it is likely that air trapping is taking place.
2. Listen to the patient’s breath sounds for a pause at the end of exhalation before the next inspiration begins. If there is no end-expiratory pause before the next breath, it is likely that the patient is air trapping.

If auto-PEEP is identified, expiratory retard can be added to reduce it. Too little retard results in some air trapping and an incompletely exhaled tidal volume. Too much retard results in an uncomfortably long expiratory time and additional air trapping. This would cause an increased mean intrathoracic pressure. The proper amount of expiratory retard should result in the patient feeling comfortable with the breathing cycle and being able to completely exhale the delivered tidal volume. Listen to the patient’s breath sounds for a silent pause at the end of exhalation. If wheezing is present, it should be minimized when the proper amount of retard is added. This is because the back-pressure is properly adjusted to minimize small airway collapse and distal gas is fully exhaled.

Bird makes a retard cap that fits over the exhalation valve port on their permanent circuit. The cap has a series of different size holes through which the exhaled gas can pass (Figure 14-8). By rotating the cap progressively from the largest to the smallest opening and evaluating the patient at each setting, the proper size opening and amount of retard can be determined. The largest hole results in the least expiratory retard, while the smallest hole results in the greatest retard.

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Figure 14-8 Bird retard cap for providing adjustable expiratory resistance.

(From McPherson SP: Respiratory therapy equipment, ed 5, St Louis, 1995, Mosby.)

Bennett makes a retard exhalation valve that can be substituted for the regular exhalation valve on their permanent circuit (Figure 14-9). The valve consists of a spring attached to a nut and a diaphragm. As the nut is turned counterclockwise the spring pushes the diaphragm closer to the exhalation valve opening. This causes resistance to the exhalation of the tidal volume and a back-pressure is created against the airways. Start with the least amount of expiratory retard and evaluate the patient before increasing the amount of expiratory retard. Be aware that if too much pressure is placed against the exhalation valve opening, the patient will not be able to exhale back to atmospheric pressure. This would create PEEP and should not be done without an order from the physician.

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Figure 14-9 Bennett retard exhalation valve for providing adjustable expiratory resistance.

(From McPherson SP: Respiratory therapy equipment, ed 5, St Louis, 1995, Mosby.)

Be sure to ask the patient’s opinion about the use of expiratory retard. The conscious, cooperative patient can tell you if he or she feels like more air is getting out by the use of the retard or if the lungs feel more full because too much retard is being used. Too much retard may also make the expiratory time uncomfortably long.

Exam Hint 14-3 (ELE, WRE)

There is usually a question that requires the therapist to modify the treatment. Increase the pressure to give a larger tidal volume; decrease the pressure to give a smaller tidal volume. If the patient wants a faster breath, increase the flow.

MODULE C

Manipulate IPPB equipment by order or protocol (ELE code: IIA11b) [ELE difficulty: R, Ap, An]

1. Get the proper IPPB circuit for the patient’s treatment

The two most widely used IPPB machines are the Bird Mark 7/8 (or a variation of it found in the series) and the Bennett PR-2. Both are pneumatically powered and found in most hospitals. Each unit requires a circuit that is designed specifically for it. See Figure 14-10 for a drawing of a permanent (reusable after cleaning) and disposable circuit for a Bird machine. See Figure 14-11 for a drawing of a permanent (reusable after cleaning) and disposable circuit for a Bennett machine.

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Figure 14-10 Features of permanent and disposable Bird IPPB circuits.

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Figure 14-11 Features of permanent and disposable Bennett IPPB circuits.

2. Put the IPPB circuit together and make sure that it works properly

See Figure 14-10 for the Bird setup and Figure 14-11 for the Bennett setup.

a. General setup procedures

1. Check for plentiful source gas. Make sure that the oxygen or air tank has the proper regulator. Check the pressure in the gas cylinder.
2. Attach the high-pressure hose to the source gas and the IPPB unit at the gas inlet. Make sure that the connections are tight.
3. Bacteria filters are optional. They are inserted between the IPPB unit gas outlets and the mainstream and nebulizer hoses.
4. A cascade-type humidifier is optional. Some practitioners prefer to warm and humidify the mainstream gas before it reaches the patient.
5. Check to see that the IPPB circuit is assembled properly and that all of the connections are tight.
6. Set the initial treatment parameters for sensitivity, flow, and peak pressure. Manually cycle the unit on. Cover the mouthpiece to see that the unit cycles off at the preset pressure.
7. Add any medication to the nebulizer. Check to see that the nebulizer is producing a mist.

b. Bird setup

1. One end of the mainstream (large-bore) hose is connected to the mainstream breathing hose connector on the right side of the unit. The other end is connected to the nebulizer.
2. One end of the nebulizer (small-bore) hose is connected to the small nipple on the right-hand side of the unit. The other end is connected to a T-piece at the nebulizer.
3. A piece of small-bore hose is used to connect one limb of the T-piece and the exhalation valve. Gas flowing through this hose powers both the nebulizer and the exhalation valve.

c. Bennett setup

1. One end of the mainstream (large-bore) hose is connected to the mainstream breathing hose connector on the underside of the unit. The other end is connected to the nebulizer.
2. One end of the nebulizer (medium-bore) hose is connected to the larger of two nipples on the underside of the unit. The other end is connected to the nebulizer nipple.
3. One end of the exhalation (small-bore) hose is connected to the smaller of two nipples on the underside of the unit. The other end is connected to the exhalation valve nipple.

3. Troubleshoot any problems with the equipment

Fixing a problem is only possible after the problem has been identified. The practitioner should be familiar with both permanent and disposable types of Bird and Bennett circuits. Leaks of any sort in the circuit prevent the unit from cycling off so that the patient can exhale. Tighten any friction-fit or screw-type connections to stop the leak. A leak at the source gas connection or high-pressure hose gas inlet connection results in a rather loud hissing sound. When connections are tightened properly, the hissing and leak will stop.

Debris such as mucus or blood can plug the nebulizer capillary tube and prevent any mist from being formed. Disassemble the nebulizer and rinse it under running water to try to clear the capillary tube. Replace the nebulizer if necessary.

Exam Hint 14-4 (ELE)

Past examinations have included questions regarding the reasons that an IPPB machine would fail to cycle off. Identify the following leaks and know how to seal them: around the patient’s mouthpiece (use a Bennett seal or face mask), within the circuit (tighten all connections), cuff on a tracheostomy or endotracheal tube (inflate the cuff), defective exhalation valve (replace the circuit).

MODULE D

Respiratory care plan

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

Atelectasis is determined by characteristic chest radiograph findings and decreased or absent breath sounds over the affected area. Wheezing breath sounds is a finding indicating bronchospasm. Pulmonary edema has characteristic chest radiograph findings and cardiovascular indicators. Review the discussion on these conditions and their findings in Chapters 1 and 5. IPPB has been used in the management of patients with these conditions if other methods are not effective.

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]

IPPB should be used for hyperinflation therapy only when less expensive options (such as incentive spirometry) are shown to be impractical. One of the goals of IPPB is to give the patient larger tidal volumes than normal. The larger tidal volumes should result in breath sounds being heard more clearly at the bases of the lungs. Additional secretions may be heard in the airways if the larger tidal volumes result in their mobilization. However, if deeper breaths enable the patient to cough more effectively, additional secretions should be expectorated. Wheezing should be diminished if a bronchodilator medication is nebulized to a patient with bronchospasm.

Ask about the patient’s feelings about the treatment, and write them in the chart. Note any significant comments made by the patient. Note the patient’s preferred flow and pressure or volume settings.

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]

In order for the patient to receive the best care possible, the respiratory therapist must know the indications, contraindications, complications, and hazards of the respiratory care procedures the patient will receive. The patient must be assessed before, during, and after the treatment or procedure to determine if it was effective. The key goal of an appropriate care plan is that the patient’s condition be treated in the best way possible. Modifications to the care plan must be made, as needed, as the patient’s condition changes.

The respiratory therapist should be a member of the patient care team of the physician, nurse, and others in deciding how best to care for the patient. The following steps are necessary in developing the respiratory care plan for any patient:

1. Determine an expected outcome or goal(s).
2. Develop a plan to achieve success.
3. Decide how to measure if the goal(s) have been achieved.
4. Plan a timeline to measure the patient’s progress.
5. Document the patient’s response to care and the final outcome.

The patient should be fully cooperative to make the best use of IPPB. It may be counterproductive to try to force an IPPB treatment on a combative or uncooperative patient. A patient who has a neuromuscular deficit may need assistance in holding the IPPB circuit or keeping a good mouth seal. A mouth seal or face mask treatment may have to be given. Be prepared to make a recommendation to have a patient use either incentive spirometry, short-term continuous positive airway pressure (CPAP), or IPPB for hyperinflation therapy. Also be prepared to make a recommendation for a patient to use either a metered dose inhaler, small volume nebulizer, or IPPB for the delivery of an aerosolized medication.

d. Terminate the IPPB treatment if the patient has an adverse reaction to it (Code: IIIF1) [Difficulty: ELE: R, Ap; WRE: An]

Patient safety should always be an important consideration during the treatment. The respiratory therapist should know the complications and hazards of any patient care activity that is performed. Be prepared to stop the treatment if the patient has a sudden adverse reaction to it (for example, hemoptysis or signs and symptoms of a pneumothorax). Additionally, be prepared to recommend to the physician that the treatment be discontinued if it is likely to result in additional serious adverse reactions.

However, some adverse reaction may only require a pause or adjustment in the IPPB treatment. For example:

• If a patient hyperventilates and feels nauseated or faint, a short pause for normal breathing will help the patient feel normal again. Then IPPB can be restarted but with a slower respiratory rate or smaller tidal volume.
• The general treatment length of 15 to 20 minutes may cause fatigue. This is often seen in aged or debilitated patients. Provide a shorter but still effective treatment.
• Stop the treatment if the patient has a pulse rate change of 20% per minute or more. It is most common to see the pulse rate increase because of a nebulized bronchodilator drug. Wait for the heart rate to drop to normal before resuming the treatment. If tachycardia occurs again, discuss with the physician decreasing the medication dose.
• IPPB may cause a decreased venous return to the heart that may be shown by an increased heart rate or drop in blood pressure. Stop the treatment and monitor the patient’s vital signs. If they return to normal, give the IPPB treatment with a lower peak pressure and smaller tidal volume.

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

The contraindications, hazards, and precautions to IPPB were discussed earlier in Module A under the sections “Contraindications” and “Hazards and precautions.” The treatment should be discontinued if the patient has an untreated pneumothorax or massive hemoptysis. Other serious problems also justify the cancellation of the order.

The IPPB treatments can be discontinued if the patient’s atelectasis is resolved. Or, IPPB can be discontinued if another, less expensive treatment, such as incentive spirometry, can be properly performed by the patient.

3. Respiratory care protocols

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

b. Apply IPPB protocol (Code: IIIH8) [Difficulty: ELE: R, Ap; WRE: Ap]

The respiratory therapist may be involved in developing an individualized patient treatment plan utilizing IPPB. Review the previously listed indications and tidal volume targeting information.

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]

Because IPPB involves the patient interacting with the unit and the therapist making adjustments to the unit based on the patient’s responses, clear and simple explanations are paramount. Be prepared to make adjustments to sensitivity, flow, and pressure and coach/teach the patient to get the best results.

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

The goal of all protocols is to restore the patient’s condition to as close to normal as possible. When it is not possible to restore normal conditions, acceptable conditions must be listed as the target for care. The patient must be evaluated before, during, and after a protocol is used to determine if improvement has occurred. Based on the results of the patient assessment, the care can be upregulated (increased) or downregulated (decreased).

IPPB should be used only for hyperinflation therapy when less expensive options (such as incentive spirometry) are not practical. One of the goals of IPPB is to give the patient larger tidal volumes than normal. Bedside spirometry should confirm that IPPB is indicated and that the patient’s IPPB breath is at least 25% greater than spontaneous breaths. Breath sounds should be heard more clearly to the bases of the lungs. More secretions may be heard in the airways if the larger tidal volumes result in their mobilization. However, if the deeper breaths enable the patient to cough more effectively, more secretions should be expectorated. Wheezing should be diminished if a bronchodilator medication is nebulized to a patient with bronchospasm.

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

Inform the patient’s nurse or physician and the supervising therapist if any serious question or problem occurs with the patient. Routine communication should occur as needed between these people and any other caregiver.

4. Record and evaluate the patient’s response to the treatment, including 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]

Monitor the patient’s vital signs before, during, and after the treatment. Ask about the patient’s feelings about the treatment. Note the vital signs in the chart and add any significant comments made by the patient. Note the patient’s preferred flow and pressure or volume settings.

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

If atelectatic areas have been opened, normal breath sounds should be heard there. If a nebulized bronchodilator medication has been effective, wheezing will be diminished or absent.

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 IPPB helps to deliver a larger tidal volume to the patient, the cough may be more effective. If IPPB has been used to deliver a nebulized mucolytic drug, the patient’s sputum may be easier to expectorate.

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

Make sure that the patient’s IPPB tidal volume goal is properly calculated.

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

Common scheduling problems include meal times and prearranged procedures or therapies, such as radiology or physical therapy. Some procedures, such as giving an IPPB treatment with aerosolized medications and performing chest physiotherapy, should be performed before eating.

BIBLIOGRAPHY

AARC Clinical Practice Guideline. Incentive spirometry. Respir Care. 1991;30:1402.

AARC Clinical Practice Guideline. Intermittent positive pressure ventilation. Respir Care. 1993;38:1189.

AARC Clinical Practice Guideline. Intermittent positive pressure ventilation—2003 revision & update. Respir Care. 2003;48:540.

Branson RD, Hess DR, Chatburn RL, editors. Respiratory care equipment, ed 2, Philadelphia: Lippincott Williams & Wilkins, 1999.

Cairo JM. Lung expansion devices. In Cairo JM, Pilbeam SP, editors: Mosby’s respiratory care equipment, ed 9, St. Louis: Mosby, 2010.

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

Fink JB. Volume expansion therapy. In Burton GG, Hodgkin JE, Ward JJ, editors: Respiratory care, ed 4, Philadelphia: Lippincott, 1997.

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, ed 4, Philadelphia: Lippincott, 1997.

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

Fluck RJJr. Intermittent positive-pressure breathing devices and transport ventilators. In Barnes TA, editor: Respiratory care practice, ed 2, St Louis: Mosby, 1994.

McPherson SP. Respiratory care equipment, ed 5. St Louis: Mosby, 1995.

Miller WF. Intermittent positive pressure breathing (IPPB). In: Kacmarek RM, Stoller JK, editors. Current respiratory care. Philadelphia: BC Decker, 1988.

Respiratory Care Committee of the American Thoracic Society. Guidelines for the use of intermittent positive pressure breathing (IPPB). Respir Care. 1980;25:365.

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

Weizalis CP. Intermittent positive-pressure breathing. In Barnes TA, editor: Respiratory care practice, ed 2, St. Louis: Mosby, 1994.

Welch MA, et al. Methods of intermittent positive pressure breathing. Chest. 1980;78:463.

White GC. Equipment theory for respiratory care, ed 4. Albany, NY: Delmar, 2005.

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

SELF-STUDY QUESTIONS FOR THE ENTRY LEVEL EXAM See page 597 for answers

1. Your patient complains of difficulty in starting the IPPB treatment. You would adjust which of the following controls?

A. Pressure
B. Flow
C. Sensitivity
D. Terminal flow

2. Your patient is having difficulty keeping a tight seal around the mouthpiece. He complains that the breath is too long and takes out the mouthpiece. To help cycle off the PR-2, you would adjust which of the following?

A. Pressure
B. Flow
C. Terminal flow
D. Expiratory retard

3. Your patient is progressing to pulmonary edema. She has crackles in both lung fields, has cyanotic lips and nail beds, and is coughing up pink, frothy sputum. What O2 percentage would you recommend for her IPPB treatment?

A. 21%
B. 40%
C. 80%
D. 100%

4. All of the following indicate the need for IPPB EXCEPT

A. Delivery of medications to a patient who cannot coordinate the use of an MDI or a handheld nebulizer
B. Treatment of a comatose patient with atelectasis
C. The need for an IS substitute in a patient with an IC that is 30% of predicted
D. Treatment of a cooperative patient with atelectasis

5. You are ordered to give an IPPB treatment to a comatose patient who has lip ulcers. What patient-machine connection would you use?

A. Mouthpiece
B. Face mask
C. Bennett seal with mouthpiece
D. Endotracheal tube adapter for intubation

6. The sensitivity control should be set at what level at the start of IPPB treatment?

A. 0 cm H2O
B. -1 cm H2O
C. -3 cm H2O
D. -5 cm H2O

7. While coaching an active IPPB treatment, you notice that the needle on the pressure manometer “bounces” around as the pressure increases. To better adjust treatment to the patient’s needs, you would do which of the following?

A. Increase the flow.
B. Decrease the flow.
C. Increase the peak pressure.
D. Decrease the expiratory retard.

8. You are giving an IPPB treatment on a Bird Mark 7 unit. To give the patient 100% O2, you push in the air-mix control knob. What effect does this adjustment have on the flow rate to the patient?

A. Decreases the flow of gas
B. Increases the flow of gas
C. No effect
D. Increases the sensitivity

9. In the emergency department, you are giving an IPPB treatment with albuterol (Ventolin) to an asthmatic patient. During a break in the treatment, the patient complains that his lungs feel too full and he does not feel like all the IPPB volume is getting out. What would you recommend?

A. Increase the flow.
B. Add expiratory retard.
C. Increase the system pressure.
D. Change to 100% oxygen.

10. While giving an IPPB treatment, a hissing sound is heard and the patient complains that the inspiratory time is too long. What is the most likely problem?

A. The nebulizer hose is attached to the exhalation valve.
B. The nebulizer medication jar is loose.
C. The bacteria filter is missing.
D. The inspiratory and expiratory hoses are reversed.

11. A patient who was initially anxious about taking an IPPB treatment and needing a fast breath is now breathing in a more relaxed manner. What adjustment should be made to allow for a longer inspiratory time?

A. Decrease the peak pressure.
B. Increase the sensitivity.
C. Set the air-mix knob to allow room air to be entrained.
D. Decrease the flow.

12. A patient you are evaluating has a spontaneous VT of 400 mL and has been diagnosed with atelectasis after bowel surgery. IPPB has been ordered. What would you recommend as the minimal volume goal?

A. 300 mL
B. 400 mL
C. 500 mL
D. 800 mL

13. After 10 min of being given an IPPB treatment, the patient complains of a sharp chest pain. After a few more deep breaths, he says he is short of breath. You notice that his breath sounds are now diminished on the left side. What would you recommend?

A. Continue the treatment for the next 5 min to finish the ordered time.
B. Decrease the peak pressure and complete the ordered treatment.
C. Stop the treatment and notify the physician of the patient’s complaints.
D. Monitor the patient closely for the duration of the treatment, and notify the nurse of the patient’s complaints.

SELF-STUDY QUESTIONS FOR THE WRITTEN REGISTRY EXAM See page 622 for answers

1. You would stop an IPPB treatment under which of the following conditions?

1. You suspect that the patient has just developed a pneumothorax.
2. The patient has a difficult time keeping his lips sealed.
3. The patient feels faint and dizzy.
4. The patient coughs up a large amount of blood.

A. 1, 2
B. 3, 4
C. 2, 4
D. 1, 3, 4

2. A patient with emphysema has been changed from a handheld nebulizer to IPPB for bronchodilator therapy. While evaluating the patient during treatment, you note that her exhaled tidal volume is decreasing. She says, “I feel full; like I can’t get all of my air out.” What would you recommend?

A. Decrease the flow.
B. Add expiratory retard.
C. Increase the system pressure.
D. Pull out the air-mix knob.

3. You are delivering an IPPB treatment to an elderly patient without teeth or dentures. He has difficulty keeping his lips tight around the mouthpiece and pressure fails to rise enough to cycle off the breath. What should be done?

A. Switch the mouthpiece to a mask.
B. Increase the inspiratory flow.
C. Place nose clips on the patient.
D. Change from IPPB to incentive spirometry.

4. You are about to give an asthmatic 16-year-old patient her second IPPB treatment with a bronchodilator medication. When checking the equipment you notice that it is set with a rather fast inspiratory flow. Her chart had a note that she was very anxious when first admitted. She seems calmer now. How would you start the treatment?

A. Increase the pressure setting to deliver a larger breath.
B. Keep the flow the same to deliver a larger breath.
C. Make the machine as sensitive as possible to easily trigger it.
D. Decrease the flow on the machine.

5. Your 45-year-old female 50-kg (110-pound) patient is recovering after abdominal surgery. The physician has ordered IPPB to help correct her atelectasis after incentive spirometry was found to be ineffective. Her spontaneous tidal volume is 350 mL. Based on this information, at what level should her minimum initial IPPB tidal volume be set?

A. 350 mL
B. 450 mL
C. 700 mL
D. 900 mL

6. Atelectasis has been diagnosed by chest radiograph in a patient who had recent open heart surgery. His best bedside spirometry inspiratory capacity (IC) value is 25% of his predicted. What should be recommended to treat his atelectasis problem?

A. IPPB
B. Incentive spirometry
C. Nasotracheal suctioning
D. Flutter

7. Your patient with COPD has been receiving IPPB treatments on a Bird Mark 7 for 5 days. Expiratory retard was added 4 days ago. Because the retard has not been evaluated since then, the physician asks you to do so. You proceeded to make the following adjustments in the retard cap settings and make the following observations:

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Based on this information, which retard cap setting would you recommend?

A. 1
B. 2
C. 3
D. 4

8. A 13-year-old patient with cystic fibrosis is receiving IPPB to deliver an aerosolized bronchodilator and mucolytic. You notice that the pressure gauge needle is bouncing higher and lower as she takes a breath. What should you do?

A. Increase the target pressure.
B. Increase the sensitivity setting.
C. Increase the flow.
D. Tell the patient to inhale more quickly.

9. Your patient has an IPPB tidal volume goal of 900 mL but is only exhaling 700 mL. What would you do to deliver a larger volume?

A. Increase the delivered pressure.
B. Decrease the flow.
C. Add expiratory retard.
D. Have the patient inhale more forcefully.

10. An 82-kg (180-pound) male is recovering after an accidental drug overdose. Because of hypoventilation and being semicomatose, he has developed bilateral atelectasis. Calculate the ideal minimum IPPB delivered tidal volume goal for him. His spontaneous tidal volume is 600 mL.

A. 700 mL
B. 900 mL
C. 1400 mL
D. 3000 mL

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