IPPB part I case studies

1. IPPB part Icase studies Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

2. Case study # 1 • Your patient is a 65 year old WF who just had pelvic surgery. She is in traction. To treat her effectively, what do you want to assess at this point?

3. answer • VS: HR is 120 bpm, RR 28 bpm • LOC: she is sleepy and complaining of pain but answers appropriately • Breath sounds: diminished basal breath sounds and rhonchi and crackles in the upper lobes • Prior medical history: in good health prior to this surgery

4. Based on the data you have collected what else might you want to see?

5. answer • Sp02 for s/s of respiratory distress: Sp02 88% • Inspection for labored breathing and for chest wall movement: poor chest wall movement, with substernal retractions

6. What do you think is wrong with this lady?

7. answer • She is suffering post-op atelectasis and she is hypoxic on room air

8. What do you want to do for this patient FIRST?

9. ANSWER: • Start 02 to get her Sp02 above 92%

10. After you start her on 2 lpm nasal cannula, you see that the Sp02 is still 88%. What do you suggest to the doctor?

11. You suggest that we raise the Fi02, you might also ask for an ABG so we can calculate exactly how high to raise the Fi02 • .

12. This is done and you get a Pa02 of 57 torr on 2 lpm. Where do you want to raise the Fi02, based on this new data?

13. answer • Based on Pa02: Fi02 as Pa02 you want : Fi02 you need, you decide you need a Pa02 80 torr. 57 torr : .28 as 80 torr : X 57X = .28 (80) 57X = .28 (80) • 57 The Fi02 you need = .39 You suggest entrainment mask at 40%

14. After she is put on 40% Fi02 her Sp02 is 95% and her respiratory rate drops. • What do you want to do next?

15. ANSWER: • Start her on IS at 15 ml/kg IBW, assess her breath sounds, VS and respiratory effort for safety and efficacy of the SMI

16. How would you assess this patient after IS?

17. assess her breath sounds: BS are unchanged after 3 IS TX • VS: HR and respiratory rate continue to stay high after IS • respiratory effort for safety and efficacy of the SMI: Still with poor chest movement • She has a weak cough

18. What do you want to assess now in order to treat this patient effectively?

19. answer • Look at the X-Ray: the atelectasis has spread from the one seen on the first day • What is her IC on the IS?: the IC she gets on the IS is only 8 ml/kg IBW

20. Based on the information in the last slide, what do you want to suggest to the doctor?

21. answer • She needs IPPB at Air/Mix to deliver a Vt of at least 15 ml/Kg/ IBW • The doctor orders 2.5 mg of Albuterol in 2.5 ml of normal saline

22. How would you assess the safety & effectiveness of this therapy?

23. answer • Measure the exhaled Vt to make sure she is getting at least 15 ml/Kg IBW and that she is not exceeding 45 ml/Kg IBW: • she is getting 25 ml/kg IBW at a pressure of 18 cmH02 • VS before, 3 minutes into and after IPPB. • Her HR was 115, rose to 125 in 3 minutes and was 145 after the IPPB. Her respiratory rate on the IPPB is 15 bpm • Breath sounds before and after IPPB: • Breath sounds increased in basal posterior • Cough? • Strong cough with copious, thick green sputum

24. How do you want to modify her TX at this point?

25. Answer: • Her Vt is ok • Her respiratory rate on the IPPB needs to be 6-8 bpm to give her heart time to refill • To make sure that Albuterol is not causing the HR increase, stop TX after 3 minutes and see if the HR decreases back to baseline • To make the thick secretions thinner, suggest Acetylcysteine

26. Case study # 2 • Your patient is a 55 year old LAM who is 5’ 8’’ tall. He has been admitted for biopsy of the lung for possible lung CA [cancer] • How do you want to assess this gentleman

27. Answer: • prior medical history: • history of working with asbestos • 20 pack/year smoking history • Chronic bronchitis for several years • Inspection for s/s respiratory distress • Respiratory rate 18 bpm and with no use of accessory muscles • HR 110 bpm • Breath sounds: • Scattered rhonchi to all lobes and wheezes over the RML. A plural rub over the LLL. • Sp02 : • Sp02 is 93% on Room Air • Sputum production • Scanty, thick, yellowish sputum

28. What do you suggest to treat him at this point?

29. He doesn’t need 02 right now, but he needs a beta II bronchodilator and possibly a mucolytic by SVN. • After his surgery, he may need IS so you could start him on IS to train him prior to surgery

30. The patient goes to surgery and gets a biopsy from his Right Middle Lobar bronchus. • In recovery room, he is sleepy and you start him on IS. He only gets 8 ml/kg IBW • What do you want to assess right now?

31. Answer: • Before you decide to give him IPPB, you need to look at his post-op X-Ray to rule out the presence of a pneumothorax • He has no pneumothorax • You want to check for blood in his sputum • He coughs up a teaspoon of bloody sputum during his IS

32. What do you want to do now?

33. Answer: • IPPB is contraindicated in Hemoptysis and he has bloody sputum. • We need continue with the SVN with beta II drug, and use segmental breathing, • but we might have to consider decreasing the concentration of the Acetylcysteine from 20% to 10% [add normal saline] because Acetylcysteine can make bleeding worse by triggering violent coughing

34. Case study # 3 • Your patient is a 45 year old WM who is status post [s/p] multiple trauma from a MVA [moving vehicular accident] • How do you want to assess this patient?

35. Answer: • Check chart for history of current illness [extent of injuries] • Broken ribs, chest tube placed to drain hemothorax. • VS: • RR 25, HR 118 bpm • Inspection for s/s of respiratory distress • Shallow breathing, no retractions, no flaring • Sp02: • Sp02 91% on 40% • Percussion • No hyper-resonance over the chest • BS: • Diminished BS over the LLL [area of chest tube] diminished over RLL. Rhonchi over RUL

36. What else might be assessed?

37. answer • X-ray shows: • LLL effusion, presence of chest tube in the lower portion of the chest • Check history: • no prior cardiopulmonary history • IBW 65 kg

38. What do you want to treat ?

39. answer • Start supplemental 02 to get the Sp02 above 92% • Initiate coughing, deep breathing • start IS at a minimal IC of 780-975 • If reassess BS and cough effort after IS to see if patient might need mucolytics via SVN

40. After the first IS, the patient can only get 600 ml, but he is c/o pain on inspiration • What do you do?

41. answer • Get with nurse regarding his pain medication schedule • Schedule IS to match his pain-free time

42. Patient’s pain medication is increased and he is sleepy and co-operative. • After three more IS, you note that his IC is still only 600 ml. • What else do you need to assess?

43. answer • His cough effort: • Weak and unproductive • His VS: HR 125 RR 29 bpm • His BS: • Diminished basal BS • Rhonchi and crackles over the middle and upper lobes • His X-ray • The effusion has almost resolved • Atelectasis in the LLL and the RLL

44. What do you want to do now?

45. answer • Start IPPB at 975 ml to treat atelectasis • Follow-up X-ray and BS to assess • Give beta II drug with normal saline • Follow-up BS and VS to effectiveness and safety