CH. 42 & 43

In performing the sustained maximal inspiration maneuver during incentive spirometry, the patient should be instructed to sustain the breath for at least how long?

5 to 10 sec Instruct the patient to sustain his or her maximal inspiratory volume for 5 to 10 sec.

In terms of machine performance, what do large negative pressure swings early in inspiration typically indicate?

Incorrect sensitivity In terms of machine performance, large negative pressure swings early in inspiration indicate an incorrect sensitivity or trigger setting.

In teaching a patient to perform the sustained maximal inspiration maneuver during incentive spirometry, what would you say?

"Exhale normally, then inhale as deeply as you can, then hold your breath for 5 to 10 seconds." The patient should be instructed to inspire slowly and deeply to maximize the distribution of ventilation.

Which of the following patient groups should be considered for lung expansion therapy using intermittent positive-pressure breathing (IPPB)? 1. Patients with clinically diagnosed atelectasis who are not responsive to other therapies 2. Patients at high risk for atelectasis who cannot cooperate with other methods 3. All obese patients who have undergone abdominal surgery

1 and 2 only IPPB may be useful for patients with clinically diagnosed atelectasis not responsive to other therapies, such as incentive spirometry and chest physiotherapy. In addition, IPPB may be useful for patients who are at high risk for atelectasis and not able to cooperate with more simple techniques such as IS.

How can the transpulmonary pressure gradient be increased? 1. Increasing alveolar pressure 2. Decreasing pleural pressure 3. Decreasing transthoracic pressure

1 and 2 only PL gradient can be increased by either decreasing the surrounding Ppl (Figure 42-1, A) or increasing the Palv.

Which of the following will make an intermittent positive-pressure breathing (IPPB) device cycle off prematurely? 1. Airflow obstructed 2. Kinked tubing 3. Occluded mouthpiece 4. Active resistance to inhalation

1, 2, 3, and 4 An IPPB device may cycle off prematurely when airflow is obstructed. Kinked tubing, an occluded mouthpiece, and active resistance to inhalation by the patient are the most common causes of this problem.

A normal cough reflex includes which of the following phases? 1. Irritation 2. Inspiration 3. Compression 4. Expulsion

1, 2, 3, and 4 As shown in Figure 43-1, there are four distinct phases to a normal cough: irritation, inspiration, compression, and expulsion.

Conditions that can affect airway patency and cause abnormal clearance of secretions include which of the following? 1. Foreign bodies 2. Tumors 3. Inflammation 4. Bronchospasm

1, 2, 3, and 4 Examples include foreign bodies, tumors, and congenital or acquired thoracic anomalies such as kyphoscoliosis. Internal obstruction also can occur with mucus hypersecretion, inflammatory changes, or bronchospasm, further narrowing the lumen.

Which of the following are the hazards and complications of incentive spirometry? 1. Hyperventilation 2. Fatigue 3. Discomfort secondary to inadequate pain control 4. Barotrauma

1, 2, 3, and 4 Hyperventilation and respiratory alkalosis, discomfort secondary to inadequate pain control, pulmonary barotrauma, exacerbation of bronchospasm, and fatigue are the hazards and complications of incentive spirometry.

What should the monitoring of patients using incentive spirometry include? 1. Number of breaths per session 2. Volume and flow goals achieved 3. Maintenance of breath-hold 4. Patient effort and motivation

1, 2, 3, and 4 See Box 42-5.

Which of the following are potential hazards of intermittent positive-pressure breathing (IPPB)? 1. Air trapping, auto-PEEP 2. Hyperventilation 3. Nosocomial infection 4. Increased airway resistance

1, 2, 3, and 4 See Box 42-7.

Which of the following should be charted in the patient's medical record after completion of an intermittent positive-pressure breathing treatment? 1. Results of pretreatment and posttreatment assessment 2. Any side effects 3. Duration of therapeutic session

1, 2, and 3 A succinct but complete account of the treatment session, including the preassessment and postassessment results, must be entered in the patient's medical record according to the approved institutional protocol. Any untoward patient responses must also immediately be reported to responsible personnel, to include at least the prescribing physician and attending nurse.

Which of the following situations is a contraindication for incentive spirometry? 1. A patient whose vital capacity is less than 10 ml/kg 2. A patient who cannot cooperate or follow instructions 3. An unconscious patient

1, 2, and 3 Incentive spirometry is a simple and relatively safe modality. For this reason, contraindications are few (Box 42-2).

Which of the following are potential indications for incentive spirometry? 1. A restrictive disorder such as quadriplegia 2. Abdominal surgery in a COPD patient 3. Presence of pulmonary atelectasis

1, 2, and 3 Indications for incentive spirometry are listed in Box 42-1.

Which of the following patient categories are at high risk for developing atelectasis? 1. Those who are heavily sedated 2. Those with abdominal or thoracic pain 3. Those with neuromuscular disorders

1, 2, and 3 Patients who have difficulty taking deep breaths without assistance include those with significant obesity, those with neuromuscular disorders, those under heavy sedation, and those who have undergone upper abdominal or thoracic surgery.

Partial airway obstruction can result in which of the following? 1. Increased work of breathing 2. Air trapping or overdistention 3. Increased expiratory flows 4. Ventilation/perfusion ratio (mc043-1.jpg) imbalances

1, 2, and 3 only By restricting airflow, partial obstruction can increase the work of breathing and lead to air trapping, overdistention, and ventilation/perfusion (mc043-2.jpg) imbalances.

Preliminary planning for intermittent positive-pressure breathing (IPPB) should include which of the following? 1. Evaluating alternative approaches to the patient's problem 2. Setting specific, individual clinical goals or objectives 3. Conducting a baseline assessment of the patient 4. Taking a chest x-ray

1, 2, and 3 only Effective IPPB requires careful preliminary planning, individualized patient assessment and implementation, and thoughtful follow-up. In all three phases of the process, the respiratory therapist should work closely with the prescribing physician to determine patient need, select the appropriate therapeutic approach, and assess patient progress toward predefined clinical outcomes.

Which of the following statements are true about intermittent positive-pressure breathing (IPPB)? 1. IPPB could cause lung overinflation. 2. IPPB could cause no expansion of regions affected by secretions. 3. Bronchial hygiene must be used in conjunction with IPPB to adequately manage secretions. 4. IPPB should be the single treatment modality for gas absorption atelectasis.

1, 2, and 3 only In either case, IPPB should not be used as a single treatment modality for the patient with gas absorption atelectasis due to excessive airway secretions. Applying positive pressure to the lung in such cases is likely to cause overinflation of the lung regions not affected by secretions and minimal or no expansion of the affected lung segments. Bronchial hygiene with humidity therapy must be used in conjunction with IPPB for the most optimal results in such cases.

Which of the following are necessary for normal airway clearance? 1. Patent airway 2. Functional mucociliary escalator 3. Effective cough 4. Normal pulmonary compliance

1, 2, and 3 only Normal airway clearance requires a patent airway, a functional mucociliary escalator, and an effective cough.

Which of the outcomes would indicate improvement in a patient previously diagnosed with atelectasis who has been receiving incentive spirometry? 1. Improved PaO2 2. Decreased respiratory rate 3. Improved chest radiograph 4. Decreased forced vital capacity (FVC)

1, 2, and 3 only See Box 42-4.

Which of the following are potential contraindications for intermittent positive-pressure breathing? 1. Hemodynamic instability 2. Recent esophageal surgery 3. Tension pneumothorax 4. Neuromuscular disorders

1, 2, and 3 only See Box 42-6.

Which of the following parameters should be evaluated after intermittent positive-pressure breathing therapy? 1. Vital signs 2. Sensorium 3. Breath sounds 4. Temperature

1, 2, and 3 only The general follow-up evaluation of the patient's clinical status should focus on determining any pertinent changes in vital signs, sensorium, and breath sounds, with emphasis on identifying possible untoward effects.

Which of the following are potential desirable outcomes of intermittent positive-pressure breathing (IPPB) therapy? 1. Improved oxygenation 2. Increased cough and secretion clearance 3. Improved breath sounds 4. Reduced pulmonary compliance

1, 2, and 4 only Box 42-8 lists potential accepted and desired outcomes of IPPB therapy.

Which of the following are potential hazards or complications of incentive spirometry? 1. Pulmonary barotrauma 2. Decreased cardiac output 3. Respiratory alkalosis 4. Fatigue

1, 3, and 4 only See Box 42-3.

Which of the following drug categories can impair mucociliary clearance in intubated patients? 1. General anesthetics 2. Bronchodilators 3. Opiates 4. Narcotics

1, 3, and 4 only Several common drugs, including some general anesthetics and narcotic-analgesics, can depress mucociliary transport.

Which of the following clinical findings indicate the development of atelectasis? 1. Opacified areas on the chest x-ray film 2. Inspiratory and expiratory wheezing 3. Tachypnea 4. Diminished or bronchial breath sounds

1, 3, and 4 only When the atelectasis involves a more significant portion of the lungs, the patient's respiratory rate will increase proportionally. Bronchial-type breath sounds may be present as the lung becomes more consolidated with atelectasis. Diminished breath sounds are common when excessive secretions block the airways and prevent transmission of breath sounds. The chest film is often used to confirm the presence of atelectasis.

Which of the following conditions alter normal mucociliary clearance? 1. Bronchospasm 2. Cystic fibrosis (CF) 3. Ciliary dyskinesia 4. Asthma

2 and 3 only Diseases that alter normal mucociliary clearance can also cause secretion retention. CF is a common disorder in this category. In CF, the solute concentration of the mucus is altered because of abnormal sodium and chloride transport. This increases mucus viscosity and impairs its movement up the respiratory tract. Although less common, there are several conditions in which the respiratory tract cilia do not function properly. These ciliary dyskinetic syndromes also can contribute to ineffective airway clearance.

Incentive spirometry devices can generally be categorized as which of the following? 1. Pressure-oriented 2. Flow-oriented 3. Volume-oriented

2 and 3 only Incentive spirometry devices can generally be categorized as volume or flow oriented.

A physician orders bronchodilator drug therapy in combination with positive expiratory pressure (PEP). Which of the following methods could you use to provide this combined therapy? 1. Attach a dry powder inhaler in-line with the PEP apparatus. 2. Attach a metered dose inhaler to the system's one-way valve inlet. 3. Place a small volume nebulizer in-line with the PEP apparatus.

2 and 3 only See Box 43-5.

Which of the following can provoke a cough? 1. Anesthesia 2. Foreign bodies 3. Infection 4. Irritating gases

2, 3, and 4 only Infection is a good example of cough stimulation due to an inflammatory process. Foreign bodies can provoke a cough through mechanical stimulation. Chemical stimulation can occur when irritating gases are inhaled (e.g., cigarette smoke). Finally, cold air may cause thermal stimulation of sensory nerves and produce a cough.

Lung expansion methods that increase the transpulmonary pressure gradients by increasing alveolar pressure include which of the following? 1. Incentive spirometry (IS) 2. Positive end-expiration pressure therapy 3. Intermittent positive-pressure breathing (IPPB) 4. Expiratory positive airway pressure (EPAP)

2, 3, and 4 only Positive-pressure lung expansion therapies may apply pressure during inspiration only (as in IPPB), during expiration only (as in positive expiratory pressure [PEP] and EPAP), or during both inspiration and expiration (CPAP).

Postural drainage should be considered in which of the following situations? 1. In patients with chronic obstructive lung disease 2. In patients who expectorate more than 25 to 30 ml sputum per day 3. In the presence of atelectasis caused by mucus plugging 4. In patients with cystic fibrosis or bronchiectasis

2, 3, and 4 only The AARC has published Clinical Practice Guideline: Postural Drainage Therapy. See CPG 43-1.

Which of the following are goals of airway clearance therapy? 1. Help reverse the underlying disease process. 2. Help mobilize retained secretion. 3. Improve pulmonary gas exchange. 4. Reduce the work of breathing.

2, 3, and 4 only The primary goal of airway clearance therapy is to help mobilize and remove retained secretions, with the ultimate aim to improve gas exchange and reduce the work of breathing.

For patients receiving incentive spirometry, what is the minimum number of sustained maximal inspirations (SMIs) per hour that you would recommend?

5 to 10 An incentive spirometry regimen should probably aim to ensure a minimum of 5 to 10 SMI maneuvers each hour.

Persistent breathing at small tidal volumes typically results in which of the following?

Compression atelectasis Compression atelectasis is primarily caused by persistent use of small tidal volumes by the patient.

A postoperative patient using incentive spirometry complains of dizziness and numbness around the mouth after therapy sessions. What is the most likely cause of these symptoms?

Hyperventilation Dizziness and numbness around the mouth are the most frequently reported symptoms associated with respiratory alkalosis.

A 59-year-old COPD patient comes to the hospital with upper abdominal surgery. The physician diagnoses the patient with pulmonary atelectasis. The patient has a vital capacity of 25 ml/kg. Which of the following lung expansion therapy will you recommend to assist this patient's atelectasis?

Incentive spirometry

Which of the following modes of lung expansion therapy is physiologically most normal?

Incentive spirometry Although all these approaches are used in lung expansion therapy, it should be clear that those methods that decrease Ppl (e.g., incentive spirometry) have more of a physiologic effect than those that raise Palv and often are most effective.

An alert and cooperative 28-year-old woman with no prior history of lung disease underwent cesarean section 16 hr earlier. Her x-ray film currently is clear. Which of the following approaches to preventing atelectasis would you recommend for this patient?

Incentive spirometry For the patient at high risk for atelectasis (e.g., the upper abdominal surgery patient), incentive spirometry is usually used.

A surgeon writes an order for lung expansion therapy for a 28-year-old 110-lb woman who has undergone lower abdominal surgery. In evaluating this patient at the bedside, you obtain a VC of 800 ml and an IC of 44% predicted. Although a chest radiograph indicates basal atelectasis, she has no problem with retained secretions. What lung expansion treatment would you recommend?

Incentive spirometry 10 times an hour at an initial volume of 500 to 600 ml For the patient having no difficulty with secretions, if the VC exceeds 15 ml/kg of lean body weight, or the IC is greater than 33% of predicted, incentive spirometry is given.

The short-term application of inspiratory positive pressure to a spontaneously breathing patient best defines which of the following?

Intermittent positive-pressure breathing Intermittent positive-pressure breathing refers to the application of inspiratory positive pressure to a spontaneously breathing patient as an intermittent or short-term therapeutic modality.

A surgeon orders lung expansion therapy for an obtunded 68-year-old, 170-lb man who has developed atelectasis after thoracic surgery. On baseline assessment, the patient cannot perform an IC or VC maneuver, but has no evidence of retained secretions. Which of the following would you recommend?

Intermittent positive-pressure breathing (IPPB) at 6 to 8 breaths/min at 10 to 15 ml/kg If either the VC or IC is less than these threshold levels, IPPB is initiated, with the pressure gradually manipulated from the initial setting to deliver at least 15 ml/kg.

In order to eliminate leaks in an alert patient receiving intermittent positive-pressure breathing therapy, which of the following adjuncts would you first try?

Nose clips To eliminate airway leaks in the alert patient, an initial trial of nose clips may be needed until the technique is understood and the treatment can be performed without them.

The application of gravity to achieve specific clinical objectives in respiratory care best describes which of the following?

Postural drainage therapy Postural drainage therapy involves the use of gravity.

Ideally, when should high-risk surgical patients be oriented to incentive spirometry?

Preoperatively, before undergoing the surgical procedure This approach provides an opportunity to orient high-risk patients to the procedure before undergoing surgery, thereby increasing the likelihood of success when incentive spirometry is provided after surgery.

What is the major contributing factor in the development of postoperative atelectasis?

Repetitive, shallow breathing Most postoperative patients also have problems coughing effectively because of their reduced ability to take deep breaths.

Which of the following positions is ideal for intermittent positive-pressure breathing therapy?

Semi-Fowler's For best results, the patient should be in a semi-Fowler's position

Which of the following are appropriate initial settings for intermittent positive-pressure breathing given to a new patient?

Sensitivity -1 to -2 cm H2O; pressure 10 to 15 cm H2O; moderate flow A sensitivity or trigger level of 1 to 2 cm H2O is adequate for most patients. Initially, system pressure is set to between 10 and 15 cm H2O.

During administration of a continuous positive airway pressure flow mask to a patient with atelectasis, you find it difficult to maintain the prescribed airway pressure. Which of the following is the most common explanation?

System or mask leaks The most common problem with positive airway pressure therapies is system leaks.

Successful application of incentive spirometry depends on:

the effectiveness of patient teaching. Successful incentive spirometry requires effective patient teaching.