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IPPB part I case studies. Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP. 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?. answer. VS: HR is 120 bpm, RR 28 bpm

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ippb part i case studies

IPPB part Icase studies

Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

slide2
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?
answer
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
answer1
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
answer2
answer
  • She is suffering post-op atelectasis and she is hypoxic on room air
slide9
ANSWER:
  • Start 02 to get her Sp02 above 92%
slide10
After you start her on 2 lpm nasal cannula, you see that the Sp02 is still 88%. What do you suggest to the doctor?
slide11
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
  • .
slide12
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?
answer3
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%

slide14
After she is put on 40% Fi02 her Sp02 is 95% and her respiratory rate drops.
  • What do you want to do next?
slide15
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
slide17
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
answer4
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
answer5
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
answer6
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
answer7
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
case study 2
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
answer8
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
slide29
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
slide30
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?
answer9
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
answer10
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
case study 3
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?
answer11
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
answer12
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
answer13
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
slide40
After the first IS, the patient can only get 600 ml, but he is c/o pain on inspiration
  • What do you do?
answer14
answer
  • Get with nurse regarding his pain medication schedule
  • Schedule IS to match his pain-free time
slide42
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?
answer15
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
answer16
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