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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

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  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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