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effective IPPB depends on four factors:
1) An RCP who is well-trained and has knowledge of the equipment, medication, reasons for therapy, and side effects.
2) A relaxed, informed, and cooperative patient.
3) A pressure-limited IPPB machine with a measuring VT.
4) Proper instruction of the patient on breathing patterns and cough techniques.
Indications of IPPB
IPPB is a short-term (10-15) breathing treatment in which pressures above atmospheric pressure are delivered to the patients lungs via a pressure-cycled ventilator.
- * IPPB should deliver VT of 12-15 mg/kg of body weight.
- * Delivered VT depends on the patient's lungs status; decreased airway resistance results in an increased delivered VT.
- * Delivered VT may be measured with a respirometer or gas collection bag on the exhalation port.
- * The inspiratory pressure to increase delivered VT, decrease the pressure to decrease delivered VT.
Decreaced work of breathing:
- *A patient experiencing acute hypoventilation my avoid intubation and placement on mechanical ventilations by administration of frequent IPPB treatment.
- * The practitioner must encourage the patient to relax and allow the IPPB unit to do all of the work.
- * The flowmeter is inadequate to meet the patients inspiratory flow demands.
- * the delivered VT is inadequate
- * Adequate time is not allowed for passive exhalation to occure
Alteration of the inspiratory and expiratory time (I:E)
- * By placing a patient with respiratory difficulties on IPPB, alveolar ventilation should be improved, therby making the patient more comfortable, less air hungry, and returning the I/E ratio and PR to normal.
- * Normal I/E ration is 1:2
- * A patient with respiratory disease experiences an increase resistance to air flow as the diameter if the airways decreaseds as a result of bronchospasm, secretions, and other factors.
- * When possitive pressure is applied to constricted airways, dilation of these airways can occur to a greater degree than with spontaneous breathing.
Cerebral blood flow alteration
- A patient receiving IPPB may experiences lightheadedness, dizziness, or faintness, from reduced PaCO2 levels and the resultant alkalemia. Decreased PaCO2 levels result in cerebral vasoconstriction, thus decreasing cerebral blood flow.
- To prevent reduced PaCO2 levels, encourage the patient to breathe slowly and to pause between breaths.
- A 50 ml flex tube should be conntected between the mouthpiece and manifold; this allows a slight rebreathing of CO2, preventing decreased PaCO2 levels.
Indications for IPPB therapy:
- Increaced working of breathing
- Inadequate cough
- Increased airway resistance
- Pulmonary edema
- Aid in weaning from continuous mechanical ventilation
Hazards of IPPB therapy:
- Excessive ventilation
- Excessive oxygenation
- Decreased Cardiac Output
- Increased ICP
- Gastric distention
- Nosocomial infection
Leads to decreased PaCO2 levels causing cerebral vasoconstriction, resulting in dizzines; patients should be instructed not to stand or walk immediately after treatment.
Patients with moderate to sever COPD breathe by the "hypoxic drive" mechanism. If IPPB is given with oxygen it may elevate the PaCo2 above normal level ( 50-65mm Hg) knocking out their drive to breathe.
Decreased Cardiac Output:
- Positive pressure applied to the airways is likewise exerted on blood vessels returning blood to the heart. This restricts venous return to the heart, which in turn decreases cardiac output from the left ventricle
- Avoding high inspiratory pressure and long inspiratory time minimizes this hazard.
- If their is a decrease venous return duing the therapy, the patient may experince tachycardia, and a drop in BP; caused by decreased left ventricular filling pressure.
- Blood flow from the head is restricted as positive pressure is exerted on the superior vena cava.
- Normal ICP is less than 10 mm Hg
- Using lower pressures and shorter inspiraory times, and by having the patient in a fowler's position or on the side of the bed , will minimize this hazard
- This is not a common hazard, except in patients with closed head injuries.
- Most common with COPD with bullous disease or emphysema with bleb formation.
- Patients who complain of sudden chest pain, SOB, or other breathing difficulties and who have tachycardia during IPPB must be suspected of having a pneumothorax.
- lissten with a stethoscope for bilateral breathe sounds and observe for asymmetric chest movement.
- If pneumothorax is suspected, stop the treatment immediately.
Coughing up blood
caused by swallowing air during the treatment.
Circuits should be changed every 24hrs; appropriate filters should be used on the IPPB unit to prevent mechine contamination; the practitioner should wash their hands before and after every treatment.
Contra-indications for IPPB therapy:
Untreated Pneumothorax and Hemorrhage which both are absoulte contra-indications
Relative contraindications: Under certain conditions IPPB may be given or be modified.
- Subcutaneous emphysema
- closed head injury/ ICP
- Bullous disease
- Cardiac insufficiency
- COPD with air trapping
- Uncooperative patients
May spread the disease ( safe if the patient is receiving anti-TB drugs)
Air leaks from the lungs
Closed head injury or ICP
To lessen the risk, use higher flow rates ( decreased inspiratory time) and lower peak pressures.
rupture of bullae or blebs
Monitor patients with decreased BP, decreased CO.
COPD with air trapping:
Increases air trapping causing inadvertent PEEP, which may decrease cardiac output; these patients already have hyperinflated lungs, and IPPB may worsen this condition.
positive effects of IPPB on pulmonary edema:
Decreases venous return, delivers aerosolized ethanol (40-50%) to decrease foamy edematous fluid; increases oxygenation;increases VT to improve ventilation.
how to instruct a patient during IPPB treament:
Tell the patient to sip on the mouthpice and allow the machine to fill the lungs until it cycles off. Tell the patient to hold their breath for a count of 3 before exhaling to better distribute medications and improve gas exchange. Tell the patient to pause before the next breath.
Settings for IPPB:
- Inspiratory pressure
- Flow rate
Performance elements of IPPB therapy:
- Read the patients chart
- Identify the patient
- Inform the patient
- Maintain asepsis
- Assess the patient
- Assess the chest
- Assure patient comfort
Assure patient comfort:
- Have the patient sitting preferably. or in a high fowler's position.
- Instruct the patient to tale slow deep breaths with the machine, pause at end inspiration, and exhale slow and passively.
Cough the patient:
The RCP can assist the patient in achieving a productive cough by "splinting" any surgery with the hands or a pillow, putting pressure on the epigastric area as the patient breaths. With a patient who cannot or will not cough a series of "huffing" maneuvers can be effective in the raising of secreations. the tracheostomized or intubated patients must be suctioned post-IPPB as they have lost their ability to cough.
Maintain the equipment:
After the therapy is complete, it is necessary to restore the patient to his former position. It is imperative to put back the oxygen device with the correct settings to the patient. It is necessary for the RCP to stay with the patient so the equipment can be ajusted, using the best combination of flow and volume to acheive the goals.
- Description: Length of treatment, pressures used, medications nebulized.
- Parameters: PR, RR, O2 sat before, during, and after.
- Chest Movement: bilateral air entry
- Effectiveness of cough: color, amount, breath sounds.
- Untoward reactions: any complications or hazards noted.
Bird Mark 7:
Pneumatically-powered, pressure-limited, volume-variable, pressure-cycled
Bird Mark 7 controls:
- Pressure control
- Flow-rate control
- Expiratory times
- Sensitivity control
- Hand timer (Manual)
Pressure Control of the bird mark 7:
Determines peak pressure delivered by the ventilator; At the set pressure the machine will cycle "off" and inspiration will end; range is from 0-60 cmH20. increasing pressure will increase VT, decreasing pressure will decrease VT.
Air-Mix of Bird Mark 7:
- "out-position" indicaters air dilution. FiO2 ranges from 60-90% on air mix.
- "in-position" venturi is bypassed and 100% oxygen is delivered.
Flow-Rate control of Bird Mark 7:
- The scale is made up of reference numbers and does not represent L/min
- Flow rates: 0-80 L/min on air mix; 0-50 L/min on 100% O2.
- To decrease inspiratory time, increase flow rate; to increase inspiratory times, decrease flow rate
- Flow wave patterns on bird mark7: square wave (constant flow) on 100% O2; tapered wave (decelerating flow) on air mix.
for using the bird as a ventilator
Used to adjust patient effort in cycles the ventilator into inspiratory phase; set it at -1.5 to -2.0 cm H20 negative phase.
Hand timer (manual):
"in-postion" cycles ventilator on . :out-postion" cycles ventilator off. Usally used before giving IPPB therapy to check the unit before applying it to the patient.
Pneumatically-powered, pressure-limited, pressure cycled.
Controls of Bennett PR-2:
- Pressire control: determines the peak pressure ranging from 0 to 50 cm H2O.
- Control pressure gauge: Amount of pressure to be delivered to the patient.
- System pressure gage: actial pressure delivered.
- rate control: setting the ventilator for patient demand. ranging from 0-40 bpm.
- Expiration time: allows lengthening of expirotory phase and changes the I:E ratio from normal I:1.5 used in conjunction with the rate control.
- Sensitivity control: Turning this control counterclockwise increases the sensitivity, making it easier for the patent to cycle the unit into inspiration.
- Terminal flow: Compemsaton for leaks (additional 12-15 L/min)
- Air dilution Control: allows room air for dilution of oxygen when the ventilator is powered by 100% oxygen.
- Bennett Valve.
- opens on insperation to allow gas flow to the patient and closes on expiration to terminate gas flow to the patient. ( the closeing of the valve is flow dependent)
- As the system pressure within the patient circuit increases during the inspiratory phase and move closer to equalizing with the control pressure from the regulator diluor valve. the flow from the ventilator through the Bennett valve decreases.
- When the flow decreases to the level of 1-3 Ipm, the valve will automatically close due to gravity endings inspiration.
Problems with IPPB and corrective actions
- * the patient is having difficulty cycling the IPPB into insperation; adjust sensitivity to -0.5 to -2 cm H2O.Make sure the machine is plugged in, connections are tight, lips sealed around the mouthpiece, no leaks.
- * The patient complains of dizziness, tingling, in the extremities; instruct the patient to breath slower and pause longer between breaths.
- * The if the patients HR increases; stop the treatment.
- * The patient cannot cycle the IPPB machine; make sure their are no leaks around the mouthpiece or mask, and also make sure that the bulloon is inflated in the ET tube and the tracheostomy..
- * During Inspiration the manometer needle is stays in the negative area, and than rises to the positive if not than increase the flow rate.
- * The IPPB machine reoeatedly cycles shortly after the patient has begun the expiratory phase; decrease that the rate control is turned off.