Therapeutics 2 - Quiz #4 - IPV, MetaNeb, IPPB - Powerpoint & Lab
How does circuit leaks or occlusion affect vent functions
*Circuit leaks* > stuck in inspiration and does not initiate exhale cycle *Occlusion affect* > Shorten inspiration, exhalation cycle and lowered pressured / total Vt delivered and I-time
What is the estimated delivered VT for IPPB?
*Delivered Vt = 10-15 ml/kg per IBW - To Improve lung expansion*
When is drive pressure control used? - What is the starting settings for adult/peds
*Drive pressure control is used to produce chest movement., increase this if you see minimal chest movement* Usage: 1.Start at about *20* and slowly increase - Ped's target: *25-30* - Adult's target: *35-40* (note: It may take several treatments to reach pressures)
Define the Three Components of Percussion control in IPV
*Percussion Controls:* 1. *Diffusion O2- 300 BPM "Easy"*: Percussive mechanical mixing, easiest for patient. (Small, fast waves) - *Improve gas exchange*, *CO2 Washout* and *loosen secretions* 2. *Convection CO2- 150 BPM*: Percussive convective ventilation with diffusion ( Medium waves) - *O2 Recruitment and Improve oxygenation* 3. *Perfusion Vesicular peristalsis - 100 BPM - "Hard"*: Percussive vesicular peristalsis, Highest amplitude, and hardest for patient. (Big, slow waves) - *More mobilization*
What does the "dip" indicate on a IPPB Pressure Graphs
- IPPB drops to to the base line into negative pressure. - Occurs when pt initiates a breathe that creates *enough negative pressure* to trigger an inspiration
Troubleshooting IPPB - How to fix Stuck on inspiration cycle
- Look for Disconnect circuit tubing to exhalation valve - Look for Disconnects at the test lung - Look for Small bore neb tubing disconnected from the vent
What acute dz pt benefits from IPV?
1. *Cardiopulmonary shock (fluid management)* 2.*Acute COPD (help prevent mechanical ventilation)* 3. *Smoke inhalation and/or pulmonary burns* 4. Aspiration 5. *CHF* 6.* Asthma* 7. *Atelectasis or surgery leading to atelectasis* 8. *Acute pneumonia* 9. Infants with *BPD* (Bronchopulmonary Dysplasia) Meconium (Europe)
Convective Tidal Exchange characteristics
1. *Co2 Washout* 2. *Improves gas exchange*
List the three Conceptions of Mechanical Ventilation
1. *Convective Tidal Exchange* 2. *Intrapulmonary Diffusion* 3. *Intrapulmonary Percussion*
What chronic dz pt benefits from IPV?
1. *Cystic fibrosis* 2.*Chronic bronchitis w/emphysematous changes* 3. Bronchiectasis - inflammation of lung wall 4.*Neuromuscular disease or immobility* - no effective cough 5. Fibrotic disease - excessive fibrous connective tissues 6. *Refractory hypoxemia* - Not responding to O2
Intrapulmonary Diffusion characteristics
1. *Recruitment/ Oxygenation*
What is MetaNeb's Typical Therapy Cycle? (What are the cycles and what is the amount of time in each cycle)?
1. 2.5 min CPEP ( lung expansion) 2. 2.5 min CHFO (Secretion clearance) 3. 2.5 min CPEP (Lung expansion) 4. 2.5 min CHFO (Secretion Clearance) 10 mins total treatment. Alternate between CPEP & CHFO
What are the important aspects of effective IPV treatment? (list Aerosol amt, recommended FiO2, and other settings )
1. Aerosol is delivered approx. *15 Lpm (1cc/min)* 2. If using a mask without tight seal, it *may require an increased delivery pressure* 3. If giving O2, percentage is between *40-55%* 4. Start percussive rate CCW 5. Be prepared to suction after treatment 6. Device is *NOT* gravity dependent
What is the benefits of chest physiotherapy? (list 3 benefits)
1. Assist a cough 2. Re-educate breathing muscles 3. Improve ventilation of the lungs
How does Phasitron works?
1. Both *preferential (non obstructive)* and *obstructive* airways 2. Breach the *secretion blockage* 3. Either through or around, depending on the type of secretion *(Path of least resistance)* 4. Once behind the blockage, alveoli are *recruited* and the secretion continues to be *mobilized*
What are the disease indication use for MetaNeb
1. COPD 2. Post-op airway management 3. Bronchiectasis 4. Neuromuscular disorders 5. Cystic fibrosis 6. Asthma 7. Emphysema 8. Reversal of Actelectasis 9. Chest wall trauma
IPV has potential to do (3 main outcomes)
1. Deliver bronchodilators/dense bland aerosol > promotes bronchial hygiene, reduce edema and relives bronchospasm 2. Percuss the airways to loosen secretions and improve ventilation past airway obstruction, there by allowing for more aerosol delivery to the distal airways 3. Enhance the expiratory flow velocity to improve gas exchange
When should MetaNeb be discontinued?
1. Depends on hospital protocol 2. Contraindication of the following - Secretion clearance is less than 5 CC per treatment for 24 hrs - Post Therapy chest exam shows an absence of retained secretion and atelectasis - Breathe sound have become cleared or improved.
Two ways IPV accomplish secretion clearance
1. During inspiration, a pressure is set to creates a pressure wedge to open the airway and maintains their patency. 2. The burst of air also provides intrapulmonary pneumatic percussion to loosen retained secretions. - *Air Hammer effect* >> Aid in secretion clearance
IPV is multipurpose - have combined key features from other devices/therapies. What are they?
1. High density aerosol therapy 2. *Extrathoracic percussion (CPT)* 3. *Intermittent Positive Pressure Breathing (IPPB)* 4. Mechanical chest thumpers and squeezers 5. Upper airway secretion mobilizers 6. Bi-level breathing devices 7. CPAP devices 8. *Postural drainage* (Not position dependent)
What are the Clinical Goals of IPPB Therapy
1. Improve and promote *coughing* and *secretion clearance* 2. Improve the *distribution of ventilation* 3. Deliver medications via neb
What interfaces can MetaNeb be used with?
1. In-line ventilation 2. Mouthpiece 3. Face mask 4. Tracheostomy
What are the Physiological Effects of IPPB
1. Increase mean airway pressure 2. Decrease WOB 3. Manipulate I:E ratios 4. Increase Vt 5. Increase alveolar ventilation 6. Provides mechanical bronchodilation - Increase O2 - Long I-time = Decrease E-time
Bird Mark 7 initial settings & What does ↑ flowrate do to I-time and Vt?
1. Inspiratory pressure: 15-20 cmH2O 2. Sensitivity (trigger): -2 cmH2O Flow rate (= accelerator) *↑ flowrate = ↓ I-Time = ↓ Vt* *↓ flowrate = ↑ I-Time = ↑ Vt*
Indications for MetaNeb?
1. Mobilization of secretions 2. Lung expansion therapy 3. Treatment and prevention of atelectasis 4. Need for supplemental O2
Intrapulmonary Percussion characteristics
1. Mobilize secretion
Devices in which IPV can be used?
1. Mouth piece/mask 2. *Inline during mechanical ventilation* 3. Artificial airway (Trach + ET)
How does IPV reduce cost? (List cost saving benefits of using this device)
1. Saves time giving aerosol. It is *IPPB & CPT in one* 2. Frequency of treatment can be adjusted based on improvements 3. Decreases length of hospital stay > *prevent/improves atelectasis* 4. Resolves *secretion clearance* quickly 5. Prevents a repeat of hospitalizations & *usable at home*
Birdmark 7 Controls - Flow rate
1. Scale on the control dial is made up of reference number, does not represent L/pm 2. Flow rates are *0-80 L/min* with *Air Mix on*, *0-50 L/min* on 100% O2 (*Air Mix off*) 3. ↑ the flow rate, ↓ inspiratory time, 4. ↓ the flow rate, ↑ inspiratory time, 5. Flow wave patterns are *Square (constant) with 100% O2* and *Tapered (decelerating) with the Air Mix* on.
IPPB - How does it work
1. Short-term breathing treatment. 2. Pressures above atmospheric pressure are delivered to the patient's lungs via a *pressure-cycled* ventilator 3. *Pneumatically* powered 4. Specialized form of *NIV* >> Patti described it as I.S on steroids
Lung and Bronchial Wall responses that increases FRC?
1. Spasm 2. Swelling 3. Hyperinflation > *Diaphram not recoiling > Obstructive Disease*
Lung and Bronchial Wall responses that decreases FRC?
1. Sputum 2. Collapse
What are the lung & Bronchial wall responses to disease? Hint: inflammation causes sputum and ... and ...
1. Sputum 2. Spasm 3. Swelling 4. Collapse 5. Hyperinflation
Which vent adjustment changes FiO2 and how does flow affects it
1. Total flow *↑* > FiO2 down 2. AirMix: 40-90%
Blackboard MetaNeb Video: List Two function of the Venturi device on the MetaNeb
1. Venturi creates ↓ in fluid pressure > ↑ velocity flow, and ↓ gas entrained from entrainment port and neutralizer port, which ↑ volume of gas delivered to the patient TL;DR > *↓ in fluid pressure > ↑ velocity flow > ↓ gas entrained > ↑ gas to Pt* 2. Flow amplifier responds to lung compliance and resistance. It's also a safety system for *over or under-distension.*
What are some Potential Outcomes of IPPB? (basically benefits)
1. min delivered Vt of at least 1/3 of predicted IC *(.33 x 50 ml/kg)* 2. Improved *vital capacity* 3. Increased *FEV1 or peak flow* 4. Enhanced *cough and secretion clearance* 5. Improved CXR 6. Improved breath sounds 7. Improved oxygenation 8. Favorable patient subjective response
Which vent adjustment change the delivered Vt
1. ↑ Pressure setting = ↑ Vt 2. ↑ Circuit resistance = ↓ Vt 3. ↑ in Insp. Flow rate = more pressured used overcome resistance = ↓ Vt 4. ↑ Lung compliance = ↑ Vt 5. ↑ Airmix = ↓ Vt
How does IPPB get *stuck in inspiration*
> When ventilator does not reach the set pressure during inspiration, it will not *cycle to exhalation* and the patient will be stuck on inspiration. Occurs when there are *leaks*
How does "Air Mix" affects Vt
Air Mix - entrains air, causes ↑ Flow Rate, thus ↓ Inspiration time and *↓ Vt*
Function of venturi device in IPV
Enhancing flow of gas by entraining 4 units of air for every 1 that passes through venturi, resulting in delivery of *sub-tidal volumes*. *Entrains room air at 4:1 ratio*
What are complications associated with putting a patient in the trendelenburg position?
If the patient is Obese or Orthopneic 1. Increases patient's *WOB* 2. Patient can become Cyanotic
What does IPV stand for?
Intrapulmonary Percussive Ventilation *Usable by all age groups*
Troubleshooting IPPB - How to fix Prolong inspiration time
Loosen nebulizer cup
IPV - Active Breathing Cycle is defined as
Maintains percussion during inspiration and expiration
What is chest physiotherapy?
Mobilization and removal of excess secretions from inside the lungs by physical means
Elastic and non-Elastic work defined as
Non-elastic: The *pressure that forces the gas through* the vent circuit and patient's airway is *overcoming the resistance* of those structure. Elastic: Any pressure left over that does the work of *stretching the lung and chest*. Energy used to do elastic work is stored in the stretch lungs and chest until patient is allowed to exhale (Allows normal passive exhalation). Ex: Vent pressure @ 20 cmH2O, 8 cmH2O is used to overcome resistance, leaves 12 cmH2O to stretch lung and chest. If *resistance ↑*, and uses 15 cmH2O to overcome, it leaves only 5 cmH2O, thus causes *Vt to ↓*
Troubleshooting IPPB - How to fix Bend or pinch off the circuit between the vent and exhalation valve?
Occlusion causes an increase in resistance at the tube, ↓ Vt and I-time
IPV - Passive Breathing cycle is defined as
Pt breathing aersol from nebulizer for approx 1-2 mins
List the IPV Tube color and their functions
Red: Gauge Yellow: Aerosol Green: Remote White: Phasitron
Explain the IPV setup procedure: (Powerpoint)
Summary: Connect, input med/soln, set percussion to easy, have patient get use to breathing through IPV, start percussion and look for chest wiggle. 1. Connect IPV circuit 2. Place med./ soln. in aerosol generator *(1cc= 1 min) 3. Rotate percussion control *CCW (easy) 4. Confirm and activate 50 psig gas source 5. Select IPV operating pressure *b/t 20-40 psig 6. Check all of the IPV functions ( mouthpiece, correct functions, etc.) 7. Start IPV by instructing to breathe mist x 1 minute 8. With lips tightly around mouthpiece or mask sealed against face, hold Percussive thumb button down and allow the Percussionator to keep the lungs inflated with continuous percussion 9. When desired, have patient inhale and exhale through the percussion, only releasing the thumb button to expectorate or pause therapy > This active exhalation enhances secretion mobilization 10. Adjust operational pressures up to 40 psig if desired for the desired effect 11.Have patient breathe aerosol mist when not percussing 12.Discontinue treatment when nebulizer is empty 13.Instruct patient to cough or prepare to suction
Hyperventilation is a complication of IPPB, which can lead to what?
Summary: Decreased PaCO2 > *Decreased Cerebral Blood Flow Alteration* 1. Lightheadedness, dizziness or faintness from reduced PaCO2, generally *caused by hyperventilation* 2. Decreased PaCO2 levels result in *cerebral vasoconstriction*, thus decreasing cerebral blood flow *Remedy*: Breathe more SLOWLY!
Who is Dr. Forrest Bird
Summary: He is the father of MV 1. Known as *Father of Mechanical Ventilation*. During WWII, pilots experienced altitude sickness due to piloting the newer supercharged planes. 2. Developed technologies to aid breathing >> First prototype consisted of Strawberry shortcake tins and a doorknob. >> Made *Bird Mark 7 Respirator / IPPB, IPV* (1979)
How does IPV work?
Summary: It's a form of *CPT* delivered into airways via *pneumatic device*. Also a form of High Frequency Oscillatory therapy (lab packet). 1. Uses breathing circuit called *Phasitron* to deliver mini-burst of gas into lung at 100-300 bpm > loosen and mobilize secretions towards upperairway & oropharynx 2. *High output nebulizer* provides dense aerosol to *deliver medications* and *hydrate secretions.*
What are the three therapies mode does the MetaNeb use?
Summary: It's basically a newer and more advanced IPV 1. Lung expansion (CPEP) 2. Secretion Clearance (CHFO)* 3. Aerosol delivery
What are the Indications for IPPB Therapy
Summary: Lung expansion, secretion clearance, aerosol delivery and Ventilation (blow off CO2) 1. *Improve lung expansion* 2. Presence of clinically significant *atelectasis* *When other therapies are unsuccessful* or patient cannot cooperate 3. *Inability to clear secretions adequately* due to *pathology that limits ability to ventilate or cough effectively* 4. Need for *short-term NIV support* >> Hypercapnic patients (alternative to intubation & continuous ventilatory support) 5. Need to deliver aerosol medication 6. Treatment of severe *bronchospasm* >> Other treatments/techniques not effective (MDI/nebulizer) >> Requires closely supervised trial 7. Deliver aerosol medications to patients with *Ventilatory muscle weakness, fatigue* or *chronic conditions* in which *intermittent NIV support is indicated*
List the Characteristics of IPPB
Summary: Pneumatic Positive pressure device that delivers low rate but high volume; have higher risk for barotrauma and minimal airway support 1. Positive Pressure 2. Minimal rates 3. Patient & seal dependent (Better techniques enables more Vt & Lung expansion 4. Minimal airway support 5. Pressure barotrauma risk - Can cause Pneumothorax 6. Minimal aerosol deposition 7. Force patient to take a larger Vt. than normal to get result 8. Forces patient to take a slow and deep breath 9. Pneumatic
List the Characteristics of IPV
Summary: Pneumatic Positive pressure device that delivers very fast rate; have lower risk for barotrauma and gives better airway support 1. Percussive rate (100-300) 2. Patient & seal semi-dependent (Techniques) 3. Maximal airway support/splinting 4. Minimal barotrauma risk 5. Maximum aerosol deposition 6. Pneumatic
What are the Contraindications of IPPB Therapy
Summary: Same as CPAP and other PAP therapies 1. *Tension pneumothorax (the only ABSOLUTE contraindication for IPPB therapy)* - Life threatening 2. Increased ICP > *15mmHg* 3. Hemodynamic instability 4. Recent facial, oral, or skull surgery 5. Tracheoesophageal fistula 6. Recent esophageal surgery 7. Active hemoptysis 8. Active, untreated TB 9. Radiographic evidence of blebs - (Rupture) 10. Air swallowing 11. Hiccups 12. Nausea/vomiting
What are Hazards and Complications of IPPB
Summary: Same as CPAP and other PAP therapies 1. Increased airway resistance 2. Barotrauma, pneumothorax 3. Nosocomial infection 4. *Respiratory alkalosis (hyperventilation)* 5. *Hyperoxia* (with O2 used as gas source and Air Mix off) 6. *Impaired venous return* 7. Gastric distension 8. Secretion impaction (inadequate humidity) 9. *Psychological dependence* (Addiction) 10. Impedance of venous return 11. *Exacerbation of hypoxemia* 12. *Hypoventilation* 13. Increased V/Q mismatch 14. Air trapping, auto PEEP, overdistended alveoli
Define: Autocephalad flow (Asymmetric bias flow pattern)
Summary: This is how IPV mobilizes mucus clearance 1. When gas flows over a thickly lined mucus layer, a sheer force is *directly proportional to the velocity* of the gas is produced 2. If airflow velocity is maintained and exceeds the *cohesive and/or adhesive force* of the mucus, it will move in the direction of gas flow. >> High forces > produces counter forces > mucus moves upwards towards the head
What is the workhorse of IPV? and the characteristics?
The *Phasitron* 1. *It has an I& E phase of 1:2.5* (+0.5s) 2. Gas is *entrained during insp.* from neb through entrainment port 3. *Open to ambient during expiratory phase*- exhalation port 4. *Automatically clutches to adjust each pulse* in response to the lung
Define Total Pressure (PTotal)
The force needed to push the gas through vent circuit and through the patient's airway. P (Elastic) + P (Non-elastic)
How does change in lung resistance and compliance effect delivered Vt
↑ Compliance = ↑ Vt ↑ Resistance = ↓ Vt
Changes in flow rate control dial affects I-time in what ways?
↑ the flow rate, ↓ inspiratory time, ↓ the flow rate, ↑ inspiratory time,
