RT 210 Lung Expansion / Hyperinflation TX RT 210 Hyperinflation TX

RT 210RT 210

Lung Expansion /Lung Expansion /

Hyperinflation TXHyperinflation TX

RT 210 Hyperinflation TXRT 210 Hyperinflation TX

Sustained Maximal Sustained Maximal Inhalation/Incentive Inhalation/Incentive Spirometry – SMI/ISSpirometry – SMI/IS

IndicationsIndications To improve atelectasisTo improve atelectasis To prevent atelectasisTo prevent atelectasis

Post‑opPost‑op COPDCOPD Other pulmonary complicationsOther pulmonary complications Mobilize secretionsMobilize secretions



ContraindicationsContraindications Patient unable to cooperatePatient unable to cooperate Patient unable to follow instructionsPatient unable to follow instructions Patient unconsciousPatient unconscious Patient unable to take deep breathsPatient unable to take deep breaths



HazardsHazards Ineffective unless performed correctlyIneffective unless performed correctly HyperventilationHyperventilation BarotraumaBarotrauma Discomfort secondary to painDiscomfort secondary to pain FatigueFatigue



ProcedureProcedure Slow deep inspiration Slow deep inspiration Inspiratory holdInspiratory hold Relaxed exhalationRelaxed exhalation Volume of gas moved should be Volume of gas moved should be

inspiratory capacityinspiratory capacity Maximum inhalation following a quiet Maximum inhalation following a quiet

exhalationexhalation



Procedure (cont)Procedure (cont) Coaching the patient is importantCoaching the patient is important

EncouragementEncouragement Insure proper techniqueInsure proper technique

FrequencyFrequency May be performed by patient after May be performed by patient after

instruction instruction Q 1 hour while awakeQ 1 hour while awake Follow‑up daily or PRNFollow‑up daily or PRN



EquipmentEquipment Most actually measure flow and timeMost actually measure flow and time

TriflowTriflow InspiRxInspiRx

Some measure volumeSome measure volume Bartlett Edwards (Bellows)Bartlett Edwards (Bellows) Inspiron (Vortex Principle)Inspiron (Vortex Principle)


Sustained Maximal Sustained Maximal Inhalation/Incentive Spirometry Inhalation/Incentive Spirometry

– SMI/IS– SMI/IS Patient EvaluationPatient Evaluation

AlertAlert CooperativeCooperative Physically able to increase IC greater than Physically able to increase IC greater than

VTVT Should be 3 times predicted VTShould be 3 times predicted VT






IPPBIPPB

Intermitent Positive Pressure Intermitent Positive Pressure BreathingBreathing


IPPB IndicationsIPPB Indications

PrimaryPrimary If patient has inadequate VC to If patient has inadequate VC to

facilitate a cough, VC less than 3 times facilitate a cough, VC less than 3 times predicted VT then VC less than predicted VT then VC less than 15ml/kg of ideal body weight15ml/kg of ideal body weight


IPPB IndicationsIPPB Indications

SecondarySecondary To deliver medicationTo deliver medication Improve I:E ratioImprove I:E ratio Improve cough and mobilize secretionsImprove cough and mobilize secretions Alter V/QAlter V/Q To improve or prevent atelectasisTo improve or prevent atelectasis To decrease CO2 temporarilyTo decrease CO2 temporarily


Contraindications of IPPBContraindications of IPPB

Absolute Absolute An untreated closed pneumothorax An untreated closed pneumothorax



Secondary ContraindicationsSecondary Contraindications ICP > 15mmHgICP > 15mmHg Hemodynamic instabilityHemodynamic instability Recent facial, oral, or skull surgeryRecent facial, oral, or skull surgery Tracheal-esophageal fistulaTracheal-esophageal fistula Active hemoptysisActive hemoptysis Active TBActive TB Blebs or bullaeBlebs or bullae



Hazards/ComplicationsHazards/Complications Barotrauma - pneumothoraxBarotrauma - pneumothorax Nosocomial infectionNosocomial infection HypocarbiaHypocarbia HyperoxiaHyperoxia TachypneaTachypnea Gastric distensionGastric distension Impedance of venous returnImpedance of venous return Air trappingAir trapping



Hazards/Complications (cont)Hazards/Complications (cont) Increased ICPIncreased ICP O2 induced hypoventilation in COPD O2 induced hypoventilation in COPD

patients patients Decreased cardiac outputDecreased cardiac output May cause or worsen hemoptysisMay cause or worsen hemoptysis



Hazards/Complications (cont)Hazards/Complications (cont) HyperventilationHyperventilation

DizzinessDizziness Loss of consciousnessLoss of consciousness TetanyTetany Paresthesia: Decreased cerebrovascular Paresthesia: Decreased cerebrovascular

PCO2 during hyperventilation causes PCO2 during hyperventilation causes vasoconstriction and decreased cerebral vasoconstriction and decreased cerebral blood flowblood flow


Physiologic Effects of IPPBPhysiologic Effects of IPPB

Increased intrapulmonary pressureIncreased intrapulmonary pressure Decreased venous return, worsened Decreased venous return, worsened

by increasing inspiratory timeby increasing inspiratory time May decrease cardiac outputMay decrease cardiac output Mechanical bronchodilationMechanical bronchodilation Altered I:E ratioAltered I:E ratio


Physiologic Effects of IPPBPhysiologic Effects of IPPB

Altered V/Q ratioAltered V/Q ratio Mobilization of secretionsMobilization of secretions Generally increased PaO2 and Generally increased PaO2 and

decreased PaCO2decreased PaCO2 Decreased work of breathingDecreased work of breathing


Administration of IPPB Administration of IPPB

Demonstrate set‑upDemonstrate set‑up Check for leaksCheck for leaks Patient instructionPatient instruction

Passive treatmentPassive treatment Slow deep inspiration with holdSlow deep inspiration with hold Maintain sealMaintain seal Explain nature of and expected results of RxExplain nature of and expected results of Rx Rx should be gentle start to inhalation, with Rx should be gentle start to inhalation, with

slow, deep breath, followed by passive slow, deep breath, followed by passive exhalationexhalation



Coaching patientCoaching patient Calm and reassure patient/relaxationCalm and reassure patient/relaxation Verbally instruct in timing of inspiration Verbally instruct in timing of inspiration

and expirationand expiration Total relaxed exhalationTotal relaxed exhalation



Monitoring patientMonitoring patient Breath soundsBreath sounds VT (3 times predicted VT)VT (3 times predicted VT) Respiratory rateRespiratory rate Pulse: Stop Rx when increased by 20 BPMPulse: Stop Rx when increased by 20 BPM Verbal responseVerbal response

Ask subjective responsesAsk subjective responses DizzinessDizziness TinglingTingling


PAPPAP

Define & Physiologic PrinciplesDefine & Physiologic Principles IndicationsIndications ContraindicationsContraindications Hazards & complications of CPAP (Egan Hazards & complications of CPAP (Egan

mini clinic)mini clinic) EquipmentEquipment Administer Intermittent CPAPAdminister Intermittent CPAP Monitoring and TroubleshootingMonitoring and Troubleshooting


Bird Mark 7 & 8 (10 & 14)Bird Mark 7 & 8 (10 & 14)

ClassificationClassification Positive pressure ventilator forces air into Positive pressure ventilator forces air into

lungslungs Pneumatically powered doesn't require Pneumatically powered doesn't require

electricity (gas powered)electricity (gas powered) Pneumatically driven Pneumatically driven

It's regulator is like a gauge regulators It's regulator is like a gauge regulators Pneumatically driven ceramic switchPneumatically driven ceramic switch

Single circuited: the same gas supply goes to Single circuited: the same gas supply goes to the patient that powers the machinethe patient that powers the machine



ModesModes AssistAssist

The only mode used for IPPBThe only mode used for IPPB Patient sets rate, then machine delivers ratePatient sets rate, then machine delivers rate

Assist ControlAssist Control Used for continuous ventilationUsed for continuous ventilation If patient fails to set rate, machine will deliver If patient fails to set rate, machine will deliver

preset ratepreset rate Control: machine set rate and does not allow Control: machine set rate and does not allow

patient to alter preset patternpatient to alter preset pattern



Pressure cycledPressure cycled Cycling is what ends inspirationCycling is what ends inspiration When set pressure is reached, When set pressure is reached,

machine ends inspirationmachine ends inspiration Other possibilities of cyclingOther possibilities of cycling

FlowFlow TimeTime VolumeVolume

Flow limit - can be setFlow limit - can be set



Flow patternFlow pattern Determined by 100% or air mix setting due to Determined by 100% or air mix setting due to

effects of back pressure on the Venturi gateeffects of back pressure on the Venturi gate 100% ‑ square wave, flow remains constant 100% ‑ square wave, flow remains constant

in the face of back pressure - "flow in the face of back pressure - "flow generator"generator"

Air mix ‑ decaying flow curve due to partial Air mix ‑ decaying flow curve due to partial closure of Venturi gateclosure of Venturi gate

Due to back pressure, flow decreases as Due to back pressure, flow decreases as pressure increasespressure increases



Pressure patternPressure pattern Determined by flow patternDetermined by flow pattern 100% source gas rectilinear100% source gas rectilinear Air mix parabolicAir mix parabolic



Internal resistanceInternal resistance How the flow curve is effected by back How the flow curve is effected by back

pressurepressure Air mix – low Air mix – low flow pattern is much effected by back flow pattern is much effected by back

pressurepressure



Principles of OperationPrinciples of Operation Magnetism versus gas pressureMagnetism versus gas pressure Two chambers of machine divided by a Two chambers of machine divided by a

diaphragm diaphragm Left side: same as atmospheric Left side: same as atmospheric

pressurepressure Right side - same as system pressureRight side - same as system pressure



On inspiration, diaphragm is drawn to the On inspiration, diaphragm is drawn to the right by decreased system pressure right by decreased system pressure when patient initiates a breathwhen patient initiates a breath

As pressure builds up on pressure side, As pressure builds up on pressure side, the diaphragm is pushed back to the left the diaphragm is pushed back to the left over‑coming pressure of the magnetic over‑coming pressure of the magnetic pull of the switch platepull of the switch plate

A ceramic switch is moved by diaphragm A ceramic switch is moved by diaphragm which turns gas flow on and offwhich turns gas flow on and off



SpecificationsSpecifications Flow is variable and adjustableFlow is variable and adjustable

Peak flows on 100% 0‑50 LPMPeak flows on 100% 0‑50 LPM Peak flow on air mix 0‑80 LPMPeak flow on air mix 0‑80 LPM

Venturi gateVenturi gate Open -2 cm H2OOpen -2 cm H2O Closes at 2cms H2O lower (Venturi gate Closes at 2cms H2O lower (Venturi gate

spring resistance) then peak or set spring resistance) then peak or set pressurepressure



Air Mix controllerAir Mix controller Determines 100% source gas or air mixDetermines 100% source gas or air mix Air mixAir mix

If O2 is the source gas, FIO2 will be 0.4 to 0.8 If O2 is the source gas, FIO2 will be 0.4 to 0.8 The machine functions as a pressure The machine functions as a pressure

generatorgenerator 100%100%

FIO2 will be FIO2 of source gasFIO2 will be FIO2 of source gas The machine functions as a flow generatorThe machine functions as a flow generator



Nebulizer driveNebulizer drive NonadjustableNonadjustable FIO2 will be FIO2 of source gasFIO2 will be FIO2 of source gas Breaks off gas flow before VenturiBreaks off gas flow before Venturi

PressurePressure Located on right side of ventilatorLocated on right side of ventilator Adjustable 0‑60 cmH2O (Mark‑7, 8, 10)Adjustable 0‑60 cmH2O (Mark‑7, 8, 10) In mmHg Mark‑14In mmHg Mark‑14 The closer the magnet to the clutch plate The closer the magnet to the clutch plate

the higher the pressure required to cyclethe higher the pressure required to cycle



SensitivitySensitivity Adjustable on ambient (left) side of machineAdjustable on ambient (left) side of machine The closer the clutch plate to the magnet, the less The closer the clutch plate to the magnet, the less

sensitive or more pressure required to initiate sensitive or more pressure required to initiate inspirationinspiration

Apnea TimerApnea Timer Works off of a small leak altering pressure Works off of a small leak altering pressure

internallyinternally Allows machine to be used for A/C or control modesAllows machine to be used for A/C or control modes Not used for routine IPPBNot used for routine IPPB



Bird Mark 8Bird Mark 8 Has negative expiratory pressure Has negative expiratory pressure

capabilitiescapabilities Used Q circuit set‑upUsed Q circuit set‑up Not normally used for IPPBNot normally used for IPPB



Bird Mark 10Bird Mark 10 Has flow accelerator Has flow accelerator Increases flow at end inspiration to Increases flow at end inspiration to

compensate for leakscompensate for leaks



Bird Mark 14Bird Mark 14 Has higher pressure capabilities, flow Has higher pressure capabilities, flow

acceleratoraccelerator No negative pressureNo negative pressure



CircuitCircuit Large bore tubingLarge bore tubing Side stream or mainstreamSide stream or mainstream Exhalation valveExhalation valve One small bore tubing with "Y" to allow One small bore tubing with "Y" to allow

delivery to exhalation valve and delivery to exhalation valve and nebulizer nebulizer

Mouthpiece, mask or trachea adaptorMouthpiece, mask or trachea adaptor


Bennett Ventilators Bennett Ventilators ClassificationClassification

Positive pressurePositive pressure Pneumatically poweredPneumatically powered

AP series is electricalAP series is electrical Pneumatically driven Bennett ValvePneumatically driven Bennett Valve Single circuitedSingle circuited ModesModes

Assist: only for IPPBAssist: only for IPPB Assist/Control: not for IPPB treatmentsAssist/Control: not for IPPB treatments



Flow cycledFlow cycled Pressure causes flow to drop to 1‑3 LPM and Pressure causes flow to drop to 1‑3 LPM and

ends inspirationends inspiration PR‑2 can be time cycledPR‑2 can be time cycled

Pressure limited: Preset control pressurePressure limited: Preset control pressure Decaying flow patternDecaying flow pattern Parabolic pressure patternParabolic pressure pattern Low internal resistance: back pressure Low internal resistance: back pressure

greatly influences flow patterngreatly influences flow pattern



Method of OperationMethod of Operation Bennett valve ‑ a counter balanced drum with Bennett valve ‑ a counter balanced drum with

vanes and windows allowing rotation to permit vanes and windows allowing rotation to permit flow through the windows or to stop itflow through the windows or to stop it

Sensitivity Sensitivity Adjustment to regulate patient effortAdjustment to regulate patient effort Set as sensitive as possible to insure minimal patient Set as sensitive as possible to insure minimal patient

effort effort Less than ‑2cm H2O for assist modeLess than ‑2cm H2O for assist mode

NebulizationNebulization Is off air dilutionIs off air dilution May be continuous or intermittentMay be continuous or intermittent AdjustableAdjustable



Method of OperationMethod of Operation Circuit setup Circuit setup

Large bore tubingLarge bore tubing NebulizerNebulizer Adaptor to patientAdaptor to patient Expiratory valveExpiratory valve 2 small bore tubes ‑ one for expiratory 2 small bore tubes ‑ one for expiratory

valve and other for nebulizationvalve and other for nebulization


Description of Bennett Description of Bennett Models Models

AP‑4 & 5AP‑4 & 5 Electrically poweredElectrically powered Compressor drivenCompressor driven Flow sensitiveFlow sensitive Flow cycled (1‑2 LPM)Flow cycled (1‑2 LPM) Single circuitSingle circuit Assistor onlyAssistor only Pressure limitedPressure limited Low internal resistanceLow internal resistance Decaying flow patternDecaying flow pattern Parabolic pressure patternParabolic pressure pattern



Venturi models ‑ PR‑1, PR‑2Venturi models ‑ PR‑1, PR‑2 Knob in ‑ room air entrained Knob in ‑ room air entrained Knob out ‑ 100% source gas Knob out ‑ 100% source gas Flow/Pres. characteristics same for Flow/Pres. characteristics same for

both settingboth setting Air mix delivers FIO2 above 0.40Air mix delivers FIO2 above 0.40



PR‑1PR‑1 No Adjustment of peak flowNo Adjustment of peak flow No negative pressureNo negative pressure No terminal flow (like flow accelerator No terminal flow (like flow accelerator

on Bird) to compensate for leakson Bird) to compensate for leaks


Description of Bennett Description of Bennett ModelsModels

PR‑2PR‑2 Has terminal flowHas terminal flow Peak flow deceleratorPeak flow decelerator Negative pressureNegative pressure


Description of Bennett Description of Bennett ModelsModels

AP SeriesAP Series Same Bennett valveSame Bennett valve Electrically compressor drivenElectrically compressor driven Used for home care frequentlyUsed for home care frequently


General Considerations For General Considerations For IPPB Therapeutic UnitsIPPB Therapeutic Units

Increasing pressure will increase Increasing pressure will increase volume delivered and I:E ratiovolume delivered and I:E ratio

Increasing flow rate will decrease Increasing flow rate will decrease inspiratory time and decrease I:E inspiratory time and decrease I:E ratioratio

Increasing sensitivity is desirable Increasing sensitivity is desirable unless autocycle occursunless autocycle occurs

Rate control is not used during IPPB Rate control is not used during IPPB (pure assist mode)(pure assist mode)


General Considerations For General Considerations For IPPB Therapeutic UnitsIPPB Therapeutic Units

Nebulizer should be adjusted to Nebulizer should be adjusted to create optimum aerosol production create optimum aerosol production without wasting medicationwithout wasting medication

Initial volume/pressure relationship Initial volume/pressure relationship is based upon normal compliance is based upon normal compliance value, and adjusted according to value, and adjusted according to patient response and therapeutic patient response and therapeutic goalsgoals


Documents

RT 210 Lung Expansion / Hyperinflation TX RT 210 Hyperinflation TX