CVR/Respiratory Physiotherapy- IPPB- the bird PDF

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Summary

CVR/Respiratory Physiotherapy- IPPB/The Bird...

Description

IPPB- The bird

Intermittent Positive Pressure Breathing- The Bird

The aim of Intermittent Positive Pressure Breathing (IPPB) is to provide short-term or intermittent mechanical ventilation for the purpose of augmenting lung expansion, assisting ventilation or assisting secretion clearance. IPPB is the maintenance of a positive pressure throughout inspiration, returning to atmospheric pressure during expiration. By increasing the tidal volume, the elastic recoil of the lungs and chest wall is increased thereby increasing the expiratory flow rate (litres/minute). IPPB has therefore been shown to:  Increase tidal volume  Mobilise Secretions IPPB uses a pressure limited ventilator with the patient triggering inspiration through spontaneous effort and expiration being passive.

Equipment  CareFusion Bird Mark 7 Respirator (IPPB machine)  Appropriate interface (facemask, mouthpiece or catheter mount for tracheostomy)  IPPB Flextube™ breathing system Bird®  Nose clip (may be required is mouthpiece is used)  O2 source  Normal saline Equipment Setup 1. Add 5mls sterile normal saline to nebuliser chamber 2. Attach circuit: wide and narrow bore tubing to IPPB 3. Attach appropriate delivery interface to end of tubing if not using mouthpiece provided 4. Connect the IPPB unit to an O2 port ensuring it is secure

RECOMMENDED STARTING SETTINGS Sensitivity or starting effort

Set low to allow patient to breath in easily without increasing work of breathing

Inspiratory pressure

8-15 cmH20 dependent on patient presentation

Inspiratory flow rate

Commence at mid-range Increase if patient is very breathless.

All other controls should be switched off

IPPB- The bird

Action

Rationale

1.

Establish indication for IPPB based on thorough clinical assessment and known indications and contraindications

2.

Initial set up as above

3.

Prepare the patient by giving explanation, sedation and analgesia as indicated

Minimises any distress to the patient, thus maximising effectiveness of treatment

4.

Position the patient according to Ax findings and treatment aims

To optimise ventilation

5.

Turn IPPB machine on and demonstrate function to patient using the red manual override control on the left-hand side of the ventilator

To minimise anxiety and improve initial technique

6.

Maintain the patients’ current fraction of inspired O2 (FiO2) where indicated until treatment is ready to commence.

The Mark 7 respirator will only provide approximately FiO2 0.4

7.

Using appropriate interface instruct patient to:  Inhale slowly and deeply, allowing the machine to fill their lungs with air  Pause briefly at end of inhalation then exhale

Ensure good lip seal or use nose clip for mouthpiece

8.

Use the red manual override control if the patient needs help initially to coordinate with the ventilator

To improve patient tolerance of the treatment

9.

Adjust sensitivity to match patient’s inspiratory effort

Reduce sensitivity if patient is finding it difficult to trigger

Ensure no "puffing" cheeks if using mouthpiece or facemask

Increase sensitivity if machine is auto triggering 10. Adjust inspiratory pressure for adequate volume observed by chest expansion

Until desired pressure is reached

11. Adjust inspiratory flow rate to match patients rate of breathing and allow good inspiratory breath time and expansion

To improve patient tolerance of the treatment

12. Once patient is comfortable with the technique commence cycles of treatment

Rx should consist of cycles of 6-8 breaths with rests in between. The number of cycles will be patient dependent & based on indications for treatment

13. Monitor patient throughout duration of treatment.  For any signs of distress  Synchrony with ventilator  Thoracic expansion  Auscultate  ‘Cheek filling’  Air swallowing  Abdominal distension  Pulse oximetry  Cardio-vascular instability

Patient safety

20 kPa is required for adequate cough

14. Adjust the settings as required to match patient demand, progress and treatment 15. Once the treatment has finished restore pre-treatment respiratory support and monitor to assess if this remains adequate

Patient safety

16. When treatment is complete, detach circuit from IPPB machine, discard any excess solution from nebulizer, and place circuit in plastic bag at bedside labelled with patient name and start date of use

To maintain infection control and prevent cross infection Circuits and delivery attachments are single patient use Circuits should be changed weekly if IPPB in long term use or more frequently if indicated IPPB machine must be cleaned and labelled as clean in line with trust Guideline before return to store

17. Report any adverse effects or changes in patients’ overall condition to nursing and/or medical personnel

Good professional practice

18. Clearly and fully document procedure, effects and response in patient notes

Legal requirement

Indications and Contraindications

IPPB- The bird

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Indications for IPPB Self-ventilating patients, including those with tracheostomies Segmental/lobar atelectasis Retained pulmonary secretions Poor cough mechanism

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Absolute Contraindications Undrained pneumothorax Surgical emphysema of unknown source

Relative Contraindications Haemodynamic instability/arrhythmias

Increasing intrathoracic pressure can compromise mean arterial pressure - further increases effort required to maintain adequate tissue perfusion

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Severe exacerbation chronic obstructive pulmonary disease (COPD) / Bronchospasm

Increased airway pressure will increase airway irritation and inflammatory response

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Raised intracranial pressure (ICP)

Increasing intrathoracic pressure can compromise mean arterial pressure and compromise cerebral perfusion pressure

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Proximal Tumor/obstruction

Risk of gas trapping or causing trauma

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Emphysematous Bullae

Increases risk of pneumothorax

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Recent oesophageal or lung surgery e.g. lobectomy/pneumonectomy

High airway pressure may cause trauma to the anastamosis. Check with surgeons regarding stump pressure.

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Hypotension (Systolic...