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RT 210

RT 210. Lung Expansion / Hyperinflation TX. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS. Indications To improve atelectasis To prevent atelectasis Post‑op COPD Other pulmonary complications Mobilize secretions. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS.

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RT 210

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  1. RT 210 Lung Expansion / Hyperinflation TX RT 210 Hyperinflation TX

  2. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS • Indications • To improve atelectasis • To prevent atelectasis • Post‑op • COPD • Other pulmonary complications • Mobilize secretions RT 210 Hyperinflation TX

  3. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS • Contraindications • Patient unable to cooperate • Patient unable to follow instructions • Patient unconscious • Patient unable to take deep breaths RT 210 Hyperinflation TX

  4. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS • Hazards • Ineffective unless performed correctly • Hyperventilation • Barotrauma • Discomfort secondary to pain • Fatigue RT 210 Hyperinflation TX

  5. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS • Procedure • Slow deep inspiration • Inspiratory hold • Relaxed exhalation • Volume of gas moved should be inspiratory capacity • Maximum inhalation following a quiet exhalation RT 210 Hyperinflation TX

  6. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS • Procedure (cont) • Coaching the patient is important • Encouragement • Insure proper technique • Frequency • May be performed by patient after instruction • Q 1 hour while awake • Follow‑up daily or PRN RT 210 Hyperinflation TX

  7. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS • Equipment • Most actually measure flow and time • Triflow • InspiRx • Some measure volume • Bartlett Edwards (Bellows) • Inspiron (Vortex Principle) RT 210 Hyperinflation TX

  8. Sustained Maximal Inhalation/Incentive Spirometry – SMI/IS • Patient Evaluation • Alert • Cooperative • Physically able to increase IC greater than VT • Should be 3 times predicted VT RT 210 Hyperinflation TX

  9. RT 210 Hyperinflation TX

  10. RT 210 Hyperinflation TX

  11. RT 210 Hyperinflation TX

  12. RT 210 Hyperinflation TX

  13. IPPB Intermitent Positive Pressure Breathing RT 210 Hyperinflation TX

  14. IPPB Indications • Primary • If patient has inadequate VC to facilitate a cough, VC less than 3 times predicted VT then VC less than 15ml/kg of ideal body weight RT 210 Hyperinflation TX

  15. IPPB Indications • Secondary • To deliver medication • Improve I:E ratio • Improve cough and mobilize secretions • Alter V/Q • To improve or prevent atelectasis • To decrease CO2 temporarily RT 210 Hyperinflation TX

  16. Contraindications of IPPB • Absolute • An untreated closed pneumothorax RT 210 Hyperinflation TX

  17. Contraindications of IPPB • Secondary Contraindications • ICP > 15mmHg • Hemodynamic instability • Recent facial, oral, or skull surgery • Tracheal-esophageal fistula • Active hemoptysis • Active TB • Blebs or bullae RT 210 Hyperinflation TX

  18. Contraindications of IPPB • Hazards/Complications • Barotrauma - pneumothorax • Nosocomial infection • Hypocarbia • Hyperoxia • Tachypnea • Gastric distension • Impedance of venous return • Air trapping RT 210 Hyperinflation TX

  19. Contraindications of IPPB • Hazards/Complications (cont) • Increased ICP • O2 induced hypoventilation in COPD patients • Decreased cardiac output • May cause or worsen hemoptysis RT 210 Hyperinflation TX

  20. Contraindications of IPPB • Hazards/Complications (cont) • Hyperventilation • Dizziness • Loss of consciousness • Tetany • Paresthesia: Decreased cerebrovascular PCO2 during hyperventilation causes vasoconstriction and decreased cerebral blood flow RT 210 Hyperinflation TX

  21. Physiologic Effects of IPPB • Increased intrapulmonary pressure • Decreased venous return, worsened by increasing inspiratory time • May decrease cardiac output • Mechanical bronchodilation • Altered I:E ratio RT 210 Hyperinflation TX

  22. Physiologic Effects of IPPB • Altered V/Q ratio • Mobilization of secretions • Generally increased PaO2 and decreased PaCO2 • Decreased work of breathing RT 210 Hyperinflation TX

  23. Administration of IPPB • Demonstrate set‑up • Check for leaks • Patient instruction • Passive treatment • Slow deep inspiration with hold • Maintain seal • Explain nature of and expected results of Rx • Rx should be gentle start to inhalation, with slow, deep breath, followed by passive exhalation RT 210 Hyperinflation TX

  24. Administration of IPPB • Coaching patient • Calm and reassure patient/relaxation • Verbally instruct in timing of inspiration and expiration • Total relaxed exhalation RT 210 Hyperinflation TX

  25. Administration of IPPB • Monitoring patient • Breath sounds • VT (3 times predicted VT) • Respiratory rate • Pulse: Stop Rx when increased by 20 BPM • Verbal response • Ask subjective responses • Dizziness • Tingling RT 210 Hyperinflation TX

  26. PAP • Define & Physiologic Principles • Indications • Contraindications • Hazards & complications of CPAP (Egan mini clinic) • Equipment • Administer Intermittent CPAP • Monitoring and Troubleshooting RT 210 Hyperinflation TX

  27. Bird Mark 7 & 8 (10 & 14) • Classification • Positive pressure ventilator forces air into lungs • Pneumatically powered doesn't require electricity (gas powered) • Pneumatically driven • It's regulator is like a gauge regulators • Pneumatically driven ceramic switch • Single circuited: the same gas supply goes to the patient that powers the machine RT 210 Hyperinflation TX

  28. Bird Mark 7 & 8 (10 & 14) • Modes • Assist • The only mode used for IPPB • Patient sets rate, then machine delivers rate • Assist Control • Used for continuous ventilation • If patient fails to set rate, machine will deliver preset rate • Control: machine set rate and does not allow patient to alter preset pattern RT 210 Hyperinflation TX

  29. Bird Mark 7 & 8 (10 & 14) • Pressure cycled • Cycling is what ends inspiration • When set pressure is reached, machine ends inspiration • Other possibilities of cycling • Flow • Time • Volume • Flow limit - can be set RT 210 Hyperinflation TX

  30. Bird Mark 7 & 8 (10 & 14) • Flow pattern • Determined by 100% or air mix setting due to effects of back pressure on the Venturi gate • 100% ‑ square wave, flow remains constant in the face of back pressure - "flow generator" • Air mix ‑ decaying flow curve due to partial closure of Venturi gate • Due to back pressure, flow decreases as pressure increases RT 210 Hyperinflation TX

  31. Bird Mark 7 & 8 (10 & 14) • Pressure pattern • Determined by flow pattern • 100% source gas rectilinear • Air mix parabolic RT 210 Hyperinflation TX

  32. Bird Mark 7 & 8 (10 & 14) • Internal resistance • How the flow curve is effected by back pressure • Air mix – low • flow pattern is much effected by back pressure RT 210 Hyperinflation TX

  33. Bird Mark 7 & 8 (10 & 14) • Principles of Operation • Magnetism versus gas pressure • Two chambers of machine divided by a diaphragm • Left side: same as atmospheric pressure • Right side - same as system pressure RT 210 Hyperinflation TX

  34. Bird Mark 7 & 8 (10 & 14) • On inspiration, diaphragm is drawn to the right by decreased system pressure when patient initiates a breath • As pressure builds up on pressure side, the diaphragm is pushed back to the left over‑coming pressure of the magnetic pull of the switch plate • A ceramic switch is moved by diaphragm which turns gas flow on and off RT 210 Hyperinflation TX

  35. Bird Mark 7 & 8 (10 & 14) • Specifications • Flow is variable and adjustable • Peak flows on 100% 0‑50 LPM • Peak flow on air mix 0‑80 LPM • Venturi gate • Open -2 cm H2O • Closes at 2cms H2O lower (Venturi gate spring resistance) then peak or set pressure RT 210 Hyperinflation TX

  36. Bird Mark 7 & 8 (10 & 14) • Air Mix controller • Determines 100% source gas or air mix • Air mix • If O2 is the source gas, FIO2 will be 0.4 to 0.8 • The machine functions as a pressure generator • 100% • FIO2 will be FIO2 of source gas • The machine functions as a flow generator RT 210 Hyperinflation TX

  37. Bird Mark 7 & 8 (10 & 14) • Nebulizer drive • Nonadjustable • FIO2 will be FIO2 of source gas • Breaks off gas flow before Venturi • Pressure • Located on right side of ventilator • Adjustable 0‑60 cmH2O (Mark‑7, 8, 10) • In mmHg Mark‑14 • The closer the magnet to the clutch plate the higher the pressure required to cycle RT 210 Hyperinflation TX

  38. Bird Mark 7 & 8 (10 & 14) • Sensitivity • Adjustable on ambient (left) side of machine • The closer the clutch plate to the magnet, the less sensitive or more pressure required to initiate inspiration • Apnea Timer • Works off of a small leak altering pressure internally • Allows machine to be used for A/C or control modes • Not used for routine IPPB RT 210 Hyperinflation TX

  39. Bird Mark 7 & 8 (10 & 14) • Bird Mark 8 • Has negative expiratory pressure capabilities • Used Q circuit set‑up • Not normally used for IPPB RT 210 Hyperinflation TX

  40. Bird Mark 7 & 8 (10 & 14) • Bird Mark 10 • Has flow accelerator • Increases flow at end inspiration to compensate for leaks RT 210 Hyperinflation TX

  41. Bird Mark 7 & 8 (10 & 14) • Bird Mark 14 • Has higher pressure capabilities, flow accelerator • No negative pressure RT 210 Hyperinflation TX

  42. Bird Mark 7 & 8 (10 & 14) • Circuit • Large bore tubing • Side stream or mainstream • Exhalation valve • One small bore tubing with "Y" to allow delivery to exhalation valve and nebulizer • Mouthpiece, mask or trachea adaptor RT 210 Hyperinflation TX

  43. Bennett Ventilators Classification • Positive pressure • Pneumatically powered • AP series is electrical • Pneumatically driven Bennett Valve • Single circuited • Modes • Assist: only for IPPB • Assist/Control: not for IPPB treatments RT 210 Hyperinflation TX

  44. Bennett Ventilators Classification • Flow cycled • Pressure causes flow to drop to 1‑3 LPM and ends inspiration • PR‑2 can be time cycled • Pressure limited: Preset control pressure • Decaying flow pattern • Parabolic pressure pattern • Low internal resistance: back pressure greatly influences flow pattern RT 210 Hyperinflation TX

  45. Bennett Ventilators ClassificationMethod of Operation • Bennett valve ‑ a counter balanced drum with vanes and windows allowing rotation to permit flow through the windows or to stop it • Sensitivity • Adjustment to regulate patient effort • Set as sensitive as possible to insure minimal patient effort • Less than ‑2cm H2O for assist mode • Nebulization • Is off air dilution • May be continuous or intermittent • Adjustable RT 210 Hyperinflation TX

  46. Bennett Ventilators ClassificationMethod of Operation • Circuit setup • Large bore tubing • Nebulizer • Adaptor to patient • Expiratory valve • 2 small bore tubes ‑ one for expiratory valve and other for nebulization RT 210 Hyperinflation TX

  47. Description of Bennett Models • AP‑4 & 5 • Electrically powered • Compressor driven • Flow sensitive • Flow cycled (1‑2 LPM) • Single circuit • Assistor only • Pressure limited • Low internal resistance • Decaying flow pattern • Parabolic pressure pattern RT 210 Hyperinflation TX

  48. Description of Bennett Models • Venturi models ‑ PR‑1, PR‑2 • Knob in ‑ room air entrained • Knob out ‑ 100% source gas • Flow/Pres. characteristics same for both setting • Air mix delivers FIO2 above 0.40 RT 210 Hyperinflation TX

  49. Description of Bennett Models • PR‑1 • No Adjustment of peak flow • No negative pressure • No terminal flow (like flow accelerator on Bird) to compensate for leaks RT 210 Hyperinflation TX

  50. Description of Bennett Models • PR‑2 • Has terminal flow • Peak flow decelerator • Negative pressure RT 210 Hyperinflation TX

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