RT 210
Lung Expansion /
Hyperinflation TX
RT 210 Hyperinflation TX
Sustained Maximal
Inhalation/Incentive
Spirometry – SMI/IS

Indications


To improve atelectasis
To prevent atelectasis




Post-op
COPD
Other pulmonary complications
Mobilize secretions
RT 210 Hyperinflation TX
Sustained Maximal
Inhalation/Incentive
Spirometry – SMI/IS

Contraindications




Patient
Patient
Patient
Patient
unable to cooperate
unable to follow instructions
unconscious
unable to take deep breaths
RT 210 Hyperinflation TX
Sustained Maximal
Inhalation/Incentive
Spirometry – SMI/IS

Hazards





Ineffective unless performed correctly
Hyperventilation
Barotrauma
Discomfort secondary to pain
Fatigue
RT 210 Hyperinflation TX
Sustained Maximal
Inhalation/Incentive
Spirometry – SMI/IS

Procedure




Slow deep inspiration
Inspiratory hold
Relaxed exhalation
Volume of gas moved should be inspiratory
capacity

Maximum inhalation following a quiet exhalation
RT 210 Hyperinflation TX
Sustained Maximal
Inhalation/Incentive
Spirometry – SMI/IS

Procedure (cont)

Coaching the patient is important



Encouragement
Insure proper technique
Frequency



May be performed by patient after instruction
Q 1 hour while awake
Follow-up daily or PRN
RT 210 Hyperinflation TX
Sustained Maximal
Inhalation/Incentive
Spirometry – SMI/IS

Equipment

Most actually measure flow and time



Triflow
InspiRx
Some measure volume


Bartlett Edwards (Bellows)
Inspiron (Vortex Principle)
RT 210 Hyperinflation TX
Sustained Maximal
Inhalation/Incentive Spirometry –
SMI/IS

Patient Evaluation




Alert
Cooperative
Physically able to increase IC greater than VT
Should be 3 times predicted VT
RT 210 Hyperinflation TX
RT 210 Hyperinflation TX
RT 210 Hyperinflation TX
RT 210 Hyperinflation TX
RT 210 Hyperinflation TX
IPPB
Intermitent Positive Pressure
Breathing
RT 210 Hyperinflation TX
IPPB Indications

Primary

If patient has inadequate VC to facilitate a
cough, VC less than 3 times predicted VT
then VC less than 15ml/kg of ideal body
weight
RT 210 Hyperinflation TX
IPPB Indications

Secondary






To deliver medication
Improve I:E ratio
Improve cough and mobilize secretions
Alter V/Q
To improve or prevent atelectasis
To decrease CO2 temporarily
RT 210 Hyperinflation TX
Contraindications of IPPB

Absolute

An untreated closed pneumothorax
RT 210 Hyperinflation TX
Contraindications of IPPB

Secondary Contraindications







ICP > 15mmHg
Hemodynamic instability
Recent facial, oral, or skull surgery
Tracheal-esophageal fistula
Active hemoptysis
Active TB
Blebs or bullae
RT 210 Hyperinflation TX
Contraindications of IPPB
Hazards/Complications









Barotrauma - pneumothorax
Nosocomial infection
Hypocarbia
Hyperoxia
Tachypnea
Gastric distension
Impedance of venous return
Air trapping
RT 210 Hyperinflation TX
Contraindications of IPPB

Hazards/Complications (cont)




Increased ICP
O2 induced hypoventilation in COPD patients
Decreased cardiac output
May cause or worsen hemoptysis
RT 210 Hyperinflation TX
Contraindications of IPPB

Hazards/Complications (cont)

Hyperventilation




Dizziness
Loss of consciousness
Tetany
Paresthesia: Decreased cerebrovascular PCO2
during hyperventilation causes vasoconstriction
and decreased cerebral blood flow
RT 210 Hyperinflation TX
Physiologic Effects of IPPB





Increased intrapulmonary pressure
Decreased venous return, worsened by
increasing inspiratory time
May decrease cardiac output
Mechanical bronchodilation
Altered I:E ratio
RT 210 Hyperinflation TX
Physiologic Effects of IPPB




Altered V/Q ratio
Mobilization of secretions
Generally increased PaO2 and decreased
PaCO2
Decreased work of breathing
RT 210 Hyperinflation TX
Administration of IPPB
Demonstrate set-up
Check for leaks
Patient instruction








Passive treatment
Slow deep inspiration with hold
Maintain seal
Explain nature of and expected results of Rx
Rx should be gentle start to inhalation, with slow,
deep breath, followed by passive exhalation
RT 210 Hyperinflation TX
Administration of IPPB

Coaching patient



Calm and reassure patient/relaxation
Verbally instruct in timing of inspiration and
expiration
Total relaxed exhalation
RT 210 Hyperinflation TX
Administration of IPPB

Monitoring patient





Breath sounds
VT (3 times predicted VT)
Respiratory rate
Pulse: Stop Rx when increased by 20 BPM
Verbal response



Ask subjective responses
Dizziness
Tingling
RT 210 Hyperinflation TX
PAP







Define & Physiologic Principles
Indications
Contraindications
Hazards & complications of CPAP (Egan mini
clinic)
Equipment
Administer Intermittent CPAP
Monitoring and Troubleshooting
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)
Classification




Positive pressure ventilator forces air into lungs
Pneumatically powered doesn't require electricity
(gas powered)
Pneumatically driven



It's regulator is like a gauge regulators
Pneumatically driven ceramic switch
Single circuited: the same gas supply goes to the
patient that powers the machine
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)
Modes


Assist



Assist Control



The only mode used for IPPB
Patient sets rate, then machine delivers rate
Used for continuous ventilation
If patient fails to set rate, machine will deliver preset rate
Control: machine set rate and does not allow
patient to alter preset pattern
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)
Pressure cycled




Cycling is what ends inspiration
When set pressure is reached, machine
ends inspiration
Other possibilities of cycling




Flow
Time
Volume
Flow limit - can be set
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)
Flow pattern





Determined by 100% or air mix setting due to
effects of back pressure on the Venturi gate
100% - square wave, flow remains constant in the
face of back pressure - "flow generator"
Air mix - decaying flow curve due to partial closure
of Venturi gate
Due to back pressure, flow decreases as pressure
increases
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Pressure pattern



Determined by flow pattern
100% source gas rectilinear
Air mix parabolic
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Internal resistance



How the flow curve is effected by back
pressure
Air mix – low
flow pattern is much effected by back
pressure
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Principles of Operation




Magnetism versus gas pressure
Two chambers of machine divided by a
diaphragm
Left side: same as atmospheric pressure
Right side - same as system pressure
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)



On inspiration, diaphragm is drawn to the right
by decreased system pressure when patient
initiates a breath
As pressure builds up on pressure side, the
diaphragm is pushed back to the left
over-coming pressure of the magnetic pull of
the switch plate
A ceramic switch is moved by diaphragm which
turns gas flow on and off
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Specifications

Flow is variable and adjustable



Peak flows on 100% 0-50 LPM
Peak flow on air mix 0-80 LPM
Venturi gate


Open -2 cm H2O
Closes at 2cms H2O lower (Venturi gate
spring resistance) then peak or set pressure
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)
Air Mix controller



Determines 100% source gas or air mix
Air mix



If O2 is the source gas, FIO2 will be 0.4 to 0.8
The machine functions as a pressure generator
100%


FIO2 will be FIO2 of source gas
The machine functions as a flow generator
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Nebulizer drive




Nonadjustable
FIO2 will be FIO2 of source gas
Breaks off gas flow before Venturi
Pressure




Located on right side of ventilator
Adjustable 0-60 cmH2O (Mark-7, 8, 10)
In mmHg Mark-14
The closer the magnet to the clutch plate the
higher the pressure required to cycle
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)
Sensitivity



Adjustable on ambient (left) side of machine
The closer the clutch plate to the magnet, the less
sensitive or more pressure required to initiate
inspiration
Apnea Timer




Works off of a small leak altering pressure internally
Allows machine to be used for A/C or control modes
Not used for routine IPPB
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Bird Mark 8

Has negative expiratory pressure capabilities
Used Q circuit set-up

Not normally used for IPPB

RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Bird Mark 10


Has flow accelerator
Increases flow at end inspiration to
compensate for leaks
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Bird Mark 14


Has higher pressure capabilities, flow
accelerator
No negative pressure
RT 210 Hyperinflation TX
Bird Mark 7 & 8 (10 & 14)

Circuit





Large bore tubing
Side stream or mainstream
Exhalation valve
One small bore tubing with "Y" to allow
delivery to exhalation valve and nebulizer
Mouthpiece, mask or trachea adaptor
RT 210 Hyperinflation TX
Bennett Ventilators Classification


Positive pressure
Pneumatically powered




AP series is electrical
Pneumatically driven Bennett Valve
Single circuited
Modes


Assist: only for IPPB
Assist/Control: not for IPPB treatments
RT 210 Hyperinflation TX
Bennett Ventilators Classification
Flow cycled







Pressure causes flow to drop to 1-3 LPM and ends
inspiration
PR-2 can be time cycled
Pressure limited: Preset control pressure
Decaying flow pattern
Parabolic pressure pattern
Low internal resistance: back pressure greatly
influences flow pattern
RT 210 Hyperinflation TX
Bennett Ventilators Classification
Method of Operation
Bennett valve - a counter balanced drum with vanes
and windows allowing rotation to permit flow through
the windows or to stop it
Sensitivity





Adjustment to regulate patient effort
Set as sensitive as possible to insure minimal patient effort
Less than -2cm H2O for assist mode
Nebulization




Is off air dilution
May be continuous or intermittent
Adjustable
RT 210 Hyperinflation TX
Bennett Ventilators Classification
Method of Operation

Circuit setup





Large bore tubing
Nebulizer
Adaptor to patient
Expiratory valve
2 small bore tubes - one for expiratory valve
and other for nebulization
RT 210 Hyperinflation TX
Description of Bennett Models
AP-4 & 5











Electrically powered
Compressor driven
Flow sensitive
Flow cycled (1-2 LPM)
Single circuit
Assistor only
Pressure limited
Low internal resistance
Decaying flow pattern
Parabolic pressure pattern
RT 210 Hyperinflation TX
Description of Bennett Models

Venturi models - PR-1, PR-2




Knob in - room air entrained
Knob out - 100% source gas
Flow/Pres. characteristics same for both
setting
Air mix delivers FIO2 above 0.40
RT 210 Hyperinflation TX
Description of Bennett Models

PR-1



No Adjustment of peak flow
No negative pressure
No terminal flow (like flow accelerator on
Bird) to compensate for leaks
RT 210 Hyperinflation TX
Description of Bennett Models

PR-2



Has terminal flow
Peak flow decelerator
Negative pressure
RT 210 Hyperinflation TX
Description of Bennett Models

AP Series



Same Bennett valve
Electrically compressor driven
Used for home care frequently
RT 210 Hyperinflation TX
General Considerations For IPPB
Therapeutic Units




Increasing pressure will increase volume
delivered and I:E ratio
Increasing flow rate will decrease
inspiratory time and decrease I:E ratio
Increasing sensitivity is desirable unless
autocycle occurs
Rate control is not used during IPPB
(pure assist mode)
RT 210 Hyperinflation TX
General Considerations For IPPB
Therapeutic Units


Nebulizer should be adjusted to create
optimum aerosol production without
wasting medication
Initial volume/pressure relationship is
based upon normal compliance value,
and adjusted according to patient
response and therapeutic goals
RT 210 Hyperinflation TX