Egan's Chapter 43: Lung Expansion Therapy

Lung Expansion Therapy

All modes of lung expansion therapy increase lung volume by increasing the transalveolar pressure (PAL) gradient

Best done by getting patient done and moving

Lung Ex Therapy: PAL gradient can be increased by either....

1. Decreasing the surrounding Ppl (deep breathing exercises)

2. Increasing the Palv (IPPB & PEP therapy)

Gas absorption atelectasis: causes

1. Occurs either when there is a complete interruption of ventilation to a section of the lung or when there is a significant shift in "v" ̇/"Q" ̇

2. Gas distal to obstruction is absorbed by passing blood

Lobar actelectasis: causes

1. Can occur when ventilation is compromised in a larger airway or bronchus

2. Laying in bed for an abnormally long period

Compression atelectasis: causes

1. Occurs when the transthoracic pressure exceeds the transalveolar pressure

2. Anesthesia, post op

Transthoracic pressure

difference between the body and the alveoli

transalveolar pressure

greater than the transthoracic, between the alveoli and pleural

factors associated with atelectasis

1. obesity

2. neuromuscular disorders

3. heavy sedation

4. surgery near diaphragm

5. bed rest

6. poor cough

7. history of lung disease

8. restrictive chest-wall abnormalities

9. standing history of bronchitis

10. pneumonia

11. poor nutrition intake (can be seen in albumin levels, if it is less than 3.2 mg/dL --> increase risk of atelectasis due to decreased muscle strength --> diaphragm causing atelectasis)

Clinical signs of atelectasis

1. history of recent major surgery

2. tachypnea

3. fine, late-inspiratoy crackles

4. bronchial or diminished breath sound

5. tachycardia

6. increased density and signs of volume loss on chest radiograph

Incentive spirometry

1. IS devices provide visual cues to patient when desired inspiratory volume of flow is reached

2. Decreases post op, introduced before surgery and used post op

Indications for incentive spirometry

1. Presence of pulmonary atelectasis

2. Presence of conditions predisposing to atelectasis

•Upper abdominal surgery

•Thoracic surgery

•Surgery in patients with COPD

3. Presence of a restrictive lung defect associated with quadriplegia or dysfunctional diaphragm

Contraindications for incentive spirometry

1. Patient cannot be instructed or supervised to ensure appropriate use of device

2. Patient cooperation is absent, or patient is unable to understand or demonstrate proper use of device

3. Patients unable to deep breathe effectively (VC less than 10 ml/kg or IC less than predicted)

Hazards and complications of incentive spirometry

1. Hyperventilation and respiratory alkalosis

2. Discomfort secondary to inadequate pain control

3. Pulmonary barotrauma (COPD patients)

4. Exacerbation of bronchospasm

6. Fatigue (surgical patients)

Equipment for incentive spirometry

1. Typically simple, portable, and inexpensive

2. IS devices either flow oriented or volume oriented

3. Flow-oriented devices more popular because they are smaller

Administration of IS

1. Need for IS is determined by careful patient assessment (high-risk patient)

2. Effective patient teaching

•Demonstrate then observe patient

•Patient should sustain his/her maximal inspiratory effort for 5 to 10 seconds

3. Follow-up

IPPB administration

1. Preliminary Planning

•During preliminary planning, the need for IPPB is determined, and desired therapeutic outcomes are established

2. Evaluating Alternatives

•Must determine therapeutic objectives for the treatment and whether simpler and less costly methods might be as effective in achieving the desired outcomes

3. Baseline assessment

4. Discontinuation and follow-up

IPPB contraindications

1. ICP greater than 15 mm Hg

2. Hemodynamic instability

3. Active hemoptysis

4. Tracheoesophageal fistula

5. Recent esophageal surgery

6. Active, untreated tuberculosis

7. Radiographic evidence of blebs

8. Recent facial, oral, or skull surgery

9. Singultus (hiccups)

PAP: physiologic basis

1. Three current approaches to PAP therapy:

•PEP, flutter, and CPAP

2. PEP threshold, resistor, and flutter valves create expiratory positive pressure only without need for continuous flow or complex machinery

PAP: contraindications

Care should be taken that the patient does not hyperventilate during therapy

Lung expansion therapy: selecting an approach

- Chose modality that is safest, simplest, and most effective

- RT should evaluate the following before choosing a specific modality:

1. Level of patient cooperation

2. Amount of pulmonary secretions

3. Patient's spontaneous vital capacity

A patient complains of a "tingling" feeling in her lips during an incentive spirometry treatment. The RT should instruct the patient to ________________________.

A. exhale through pursed lips after each breath.

B. breath more slowly

C. continue with the treatment as ordered

D. take smaller breaths

B. breath more slowly

Which of the following alarms is a vital part of the system when setting up CPAP therapy for treatment of atelectasis?

A. exhaled volume

B. low pressure

C. pulse oximetry

D. high respiratory rate

B. low pressure

A patient is having difficulty initiating each breath with an IPPB machine. The practitioner should adjust the _____________________________.

A. pressure limit

B. peak flow

C. sensitivity

D. FiO2

C. sensitivity

Which control is used to increase the volume delivered by an IPPB machine?

A. peak flow

B. sensitivity

C. FiO2

D. pressure limit

D. pressure limit

CPAP is used to increase which of the following?

A. FRC

B. PaCO2

C. FEV1

D. PEFR

A. FRC

An IPPB machine cycles on with the patient effort but does not shut off. The most likely cause of this problem is __________________________.

A. there is a leak in the system

B. the patient is not blowing out hard enough

C. the sensitivity is set incorrectly

D. the pressure is set too low

A, there is a leak in the system

How should you instruct the patient to breathe during IS?

A. "Exhale gently, then inhale rapidly through the spirometer"

B. "Exhale normally, then inhale slowly and deeply with a 3-5 second breath hold"

C. "Exhale until your lungs are empty, then inhale and hold your breath"

D. "Inhale deeply and rapidly through the spirometer"

B. "Exhale normally, then inhale slowly and deeply with a 3-5 second breath hold"

How often should the patient be directed to perform the IS after being taught to perform the procedure correctly?

A. 10 to 20 breaths every 2 hours

B. 10 breaths every hour

C. 6 to 8 breath three times daily

D. 10 breaths once a day

B. 10 breaths every hour

A patient who has had surgery for an abdominal aortic aneurysm suffers from arrhythmias and hypotension after surgery. The physician ask for your recommendation for lung expansion therapy. The best choice in this situation is:

A. IS

B. CPAP

C. IPPB

D. PEP

A. IS

When adjusting the flow rate control on an IPPB machine, the RT would be altering the ________________.

A. maximum pressure delivered by the device

B. inspiratory time for each breath

C. effort required to initiate each breath

D. volume delivered each breath

B. inspiratory time for each breath

What are 4 procedures that increase the risk of atelectasis occurring?

1. Anesthesia use

2. Use of muscle relaxants

3. Cardiopulmonary surgery

4. Alterations in mechanic properties in lung and chest wall

What does diffusion impairment reflect and what are 3 underlying lung diseases that could contribute to this?

1. Diffusion impairment reflects the result of reduction in global perfusion of thelungs and reduction in the conductance of alveolar capillary membrane.

2. Underlying lung diseases that can cause this:

1. COPD

2. Sarcoidosis

3. Cystic fibrosis

What are 4 patient (comorbidity) related factors associated with increased risk of atelectasis occurring?

1. Not being able to clear the airway

2. Inability to open up the glottis causing mucus build up

3. Difficulty swallowing liquids causing a pool of saliva and mucus in pharynx

4. Excessive pharyngeal secretions that are similar to post-nasal drip

What happens to West lung zone 1 during general anesthesia and why?

During general anesthesia there is an increase in alveolar dead space and decreasein patient tidal volume. This is because of the positive pressure from the generalanesthesia that causes the collapse from the alveolar pressure.

What are 2 prevention methods for prevention and treatment of atelectasis?

1. Chest physiotherapy

2. Use of IS (incentive spirometry)