Volume Expansion Therapy (VET)

1. Volume Expansion Therapy (VET) RET 2275 Respiratory Care Theory 2

2. Volume Expansion Therapy (VET) • Volume Expansion Therapy • AKA • Lung expansion therapy • Hyperinflation therapy A variety or respiratory care modalities designed to prevent or correct atelectasis by augmenting lung volumes • Incentive Spirometry (IS) • Intermittent Positive Airway Pressure (IPPB) • Continuous Positive Airway Pressure (CPAP) • Positive Expiratory Pressure (PEP)

3. Volume Expansion Therapy (VET) • Atelectasis • Definition: alveolar collapse • Types: • Obstructive • Caused by mucus plugging of airways • Passive • Cause by constant tidal breathing of small volumes • Common complication in postoperative patients

4. Volume Expansion Therapy (VET) • The Sigh Mechanism • Definition:the automatic, periodic inhalation of a large tidal volume to prevent passive atelectasis • Normally, a person sighs about 6-10 times per hour • Passive atelectasis can occur if this mechanism is impaired or lost

5. Volume Expansion Therapy (VET) • The Sigh Mechanism • Factors that can impair the sigh mechanism • General anesthesia • Pain • Pain medication • Decreased level of consciousness • Thoracic or upper abdominal surgery • Impaired diaphragmatic movement

6. Volume Expansion Therapy (VET) • Sustained Maximal Inspiration (SMI) • A slow, deep inhalation form the FRC up to (ideally) the total lung capacity, followed by a 5 – 10 second breath hold • Designed to mimic natural sighing • The negative alveolar & pleural pressures reexpand collapsed alveoli and prevent the collapse of ventilated alveoli

7. Volume Expansion Therapy (VET) • Indications • Presence of pulmonary atelectasis • Presence of condition predisposing to atelectasis • Upper abdominal surgery • Thoracic surgery • Surgery in patient with COPD • Presence of a restrictive lung defect associated with quadriplegia and/or dysfunctional diaphragm

8. Volume Expansion Therapy (VET) • Contraindications for VET • Inability of patient to be instructed to perform SMI maneuver • Lack of patient cooperation • Inability of patient to deep breathe (i.e. VC <10 ml/kg)

9. Volume Expansion Therapy (VET) • Hazards & Complications of VET • Ineffective in absence of correct technique (may require repeated instruction & coaching) • Hyperventilation • Exacerbation of bronchospasm

10. Volume Expansion Therapy (VET) • Hazards & Complications of VET • Hypoxemia (if O2 therapy is interrupted) • Barotrauma (in emphysematous lungs) • Fatigue • Pain in postoperative patients

11. Volume Expansion Therapy (VET) • Assessment of Need • Evidence of atelectasis based on physical exam & x-ray findings • Upper abdominal or thoracic surgery • Presence of predisposing conditions • Presence of neuromuscular disease affecting the respiratory muscles

12. Volume Expansion Therapy (VET) • Findings Consistent with Atelectasis • Diminished breath sounds & fine crackles in affected area • Fever • Tachypnea & tachycardia • Dull percussion note • Characteristic opacity on chest x-ray

13. Volume Expansion Therapy (VET) • Incentive Spirometry Equipment • Device is only a visual aid • Importance is placed on patient performing the correct maneuver

14. Volume Expansion Therapy (VET) • Incentive Spirometry (IS) • Equipment • Volume IS

15. Volume Expansion Therapy (VET) • Incentive Spirometry (IS) • Equipment • Flow oriented • (flow x time = volume)

16. Volume Expansion Therapy (VET) • Incentive Spirometry (IS) • Administering IS • Physician order required • Instruct patient • Importance of deep breathing • Demonstration is the most effective way to assist the patient’s understanding and cooperation • Position patient • Sitting or semi-Fowler’s Semi-Fowler’s Position (Head elevated 30)

17. Volume Expansion Therapy • Incentive Spirometry (IS) • Administering IS • RT should set initial goal (e.g. certain volume) • Should require some moderate effort • Instruct patient to inspire SLOWLY and deeply • Maximizes distribution of ventilation • Ensure that the patient is using diaphragmatic breathing • Instruct patient to sustain maximal inspiratory volume for 5 – 10 seconds followed by a normal exhalation

18. Volume Expansion Therapy • Incentive Spirometry (IS) • Administering IS • Give the patient an opportunity to rest • Some patients need 30 seconds to one minute • Helps prevent hyperventilation, dizziness, numbness around the mouth, respiratory alkalosis • IS regimen should aim to ensure a minimum of 5 - 10 SMI maneuvers each hour • Once technique is mastered, minimum supervision is required

19. Volume Expansion Therapy (VET) • Assessment of Outcome • Absence of or improvement in signs of atelectasis • Normal respiratory & heart rates • Afebrile • Absence of abnormal breath sounds

20. Volume Expansion Therapy (VET) • Assessment of Outcome • Normal chest x-ray • Improved oxygenation (PaO2/SpO2) • Return of normal spirometric values • Improved respiratory muscle performance

21. Volume Expansion Therapy • Incentive Spirometry (IS) • Charting IS • Pre-treatment vital signs • HR, RR, Breath sounds • Initial goal • Example: 800 ml x 10 SMI • Patient toleration • Post-treatment vital signs • Patient education • See examples of charting notes on next slide

22. Volume Expansion Therapy (VET) • Incentive Spirometry (IS) - Charting Example of Chart Note: 1/31/06, 08:30 IS given to patient sitting in chair. HR = 80 - 72, RR = 16 - 14, Breath sounds decreased at bases bilaterally, some fine crackles noted at end inspiration. Obtained IS goal of 2.0 L x 7 SMI. Patient has a dry, non-productive cough. Breath sounds unchanged after treatment. Patient tolerated treatment without incident. Example of Patient Education Note: Instructed patient regarding the importance taking deep breaths after surgery. Demonstrated IS technique for patient. Patient verbalized understanding of therapy and gave a return demonstration with IS. Sy Big, MDC Student Respiratory Care

23. Volume Expansion Therapy (VET) • Important Points Regarding Use of IS • Verify that there is an indication for therapy • Effective patient teaching & coaching is essential • Demonstrate technique for patient • Teach splinted coughing • Place device within patient’s reach • Provide rest periods as necessary

24. CPAP • Definition • The application of a positive airway pressure to the spontaneously breathing patient throughout the respiratory cycle at pressures of 5 – 20 cm H2O

25. CPAP • Physiological Principles • CPAP elevates and maintains high alveolar and airway pressures throughout the full breathing cycle.

26. CPAP • Physiologic Principles - Equipment • The patient on CPAP breaths through a pressurized circuit against a threshold resistor, with pressures maintained between 5 – 20 cm H2O

27. CPAP • Physiologic Principles - Equipment

28. CPAP • Physiologic Principles • CPAP • Recruits collapsed alveoli via an increase in FRC

29. CPAP • Physiologic Principles • CPAP • Recruits collapsed alveoli via an increase in FRC • Decreases work of breathing due to increased compliance or abolition of auto-PEEP • Improves distribution of ventilation through collateral channels (e.g., Kohn’s pores) • Increases the efficiency of secretion removal

30. CPAP • Indications • Postoperative atelectasis • Cardiogenic pulmonary edema • Refractory hypoxemia • PaO2 <60 mm Hg, SaO2 <90% on an FiO2 >0.40 – 0.50 in the presence of adequate ventilatory status (PaCO2 <45 mm Hg, pH 7.35 – 7.45) • Obstructive sleep apnea

31. CPAP • Contraindications • Hemodynamic instability • Hypoventilation • CPAP does not ensure ventilation • Nausea • Facial trauma • Untreated pneumothorax • Elevated intracranial pressure

32. CPAP • Hazards and Complications • Increased work of breathing caused by the apparatus • Hypoventilation and hypercapnia • Patients with ventilatory insufficiency may hypoventilate during application • Barotrauma • More likely in patients with emphysema and blebs • Gastric distention (CPAP pressures >15 cm H2O) • Vomiting and aspiration in patients with an inadequate gag reflex

33. CPAP • Monitoring and Troubleshooting • Patients must be able to maintain adequate excretion of CO2 on their own • System pressure must be monitored • Alarms need to indicate system disconnect or mechanical failure • Masks may cause irritation and pain • Adequate flow to meet patient’s need • Flow initially set to 2 – 3 times the patients minute ventilation • Flow is adequate when the system pressure drops no more than 1 – 2 cm H2O during inspiration

34. CPAP • Patient Interfaces • Nasal Mask

35. CPAP • Patient Interfaces • Fitting the Nasal Mask • Dorsum of nasal bridge • Around the nasal alae • Mid philtrum • Use foam bridge • Prevents collapse of mask onto nose

36. CPAP • Patient Interfaces • Fitting the Nasal Mask • DO NOT over tighten • Tissue necrosis

37. CPAP – Tissue necrosis

38. CPAP • Patient Interfaces • Full-Face Mask

39. CPAP • Patient Interfaces • Fitting the Full-Face Mask • Dorum of nasal bridge • Surrounds nose/mouth • Rests below lower lip • DO NOT over tighten • Tissue necrosis • Foam bridge • Prevents collapse of mask onto nose

40. CPAP • Nasal vs. Full-Face Mask • Nasal Masks • More prone to air leaks (especially mouth breathers) • Use chin strap • Full-Face Mask • Increase dead space • Risk of aspiration • Claustrophobia • Interferes with expectoration of secretions, communication, eating

41. CPAP • Patient Interfaces • Total Face Mask

42. EZ-PAP • Lung expansion therapy during inspiration and PEP therapy during exhalation • Used for the treatment or prevention of atelectasis and the mobilization of secretions • Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator

43. EZ-PAP • EZ-PAP

44. EZ-PAP

45. EZ-PAP with SVN

46. IPPB • Definition • The application of inspiratory positive pressure to a spontaneously breathing patient as an intermittent or short-term therapeutic modality

47. IPPB • Definition • The delivery of a slow deep sustained inspiration by a mechanical device providing controlled positive pressure breath during inspiration

48. IPPB • Indications (AARC) • The need to improve lung expansion • Treatment of atelectasis not responsive to other therapies, (e.g., IS and CPT) • Inability to clear secretions adequately • Limited ventilation • Ineffective cough

49. IPPB • Indications (AARC) • Short-term nonivasive ventilatory support for hypercapnic patients • Alternative to intubation and continuous ventilatory support

50. IPPB • Indications (AARC) • The need to deliver aerosol medication • When MDI or nebulizer has been unsuccessful • Patients with ventilatory muscle weakness or fatigue