Chapter 39 Lung Expansion Therapy

Learning Objectives Describe the various causes of atelectasis. State who needs lung expansion therapy. Identify the clinical findings seen in atelectasis. Describe how lung expansion therapy works.

Learning Objectives (cont.) List the indications, hazards, and complications associated with the various modes of lung expansion therapy. Describe the primary responsibilities of the respiratory therapist in planning, implementing, and evaluating lung expansion therapy.

Introduction Pulmonary complications are common after surgery involving upper abdomen or thorax Such complications include atelectasis, pneumonia, & acute respiratory failure Lung expansion therapy is utilized to prevent or correct respiratory complications in postoperative period

Causes & Types of Atelectasis Gas absorption atelectasis can occur when mucus plugs block ventilation to selected regions of lung or if there is significant shift in V/Q; gas distal to obstruction is absorbed by passing blood Compression atelectasis is caused by persistent breathing with small tidal volumes and/or certain types of restrictive chest-wall disorders

Which of the following is a cause for compression atelectasis? mucus plugs blocking ventilation to selected regions of the lung significant shifts in V/Q persistent breathing with small tidal volumes excessive lung volume during normal breathing Answer: C

Factors Associated With Causing Atelectasis Obesity Neuromuscular disorders Heavy sedation Surgery near diaphragm Bed rest Poor cough History of lung disease Restrictive chest-wall abnormalities

Clinical Signs of Atelectasis History of recent major surgery Tachypnea Fine, late-inspiratory crackles Bronchial or diminished breath sounds Tachycardia Increased density & signs of volume loss on chest radiograph

All of the following are clinical signs of atelectasis, except? History of recent major surgery Tachypnea Fine, late-inspiratory crackles decreased density and signs of volume gains on the chest radiograph Answer: D

Lung Expansion Therapy Incentive spirometry Has been mainstay of lung expansion therapy for many years IS devices provide visual cues to patient when desired inspiratory volume of flow is reached Proved to be effective in high-risk patients

Incentive Spirometry

Incentive spirometry (cont.)

Lung Expansion Therapy (cont.) Equipment for incentive spirometry Typically simple, portable, & inexpensive IS devices either flow oriented or volume oriented Flow-oriented devices more popular because they are smaller

Equipment

Flow-Oriented Incentive Spirometer

Lung Expansion Therapy (cont.) Administration of IS Need for IS is determined by careful patient assessment (high-risk patient) Effective patient teaching Demonstrate then observe patient Patient should sustain his/her maximal inspiratory effort for 5 to 10 seconds Follow-up

Lung Expansion Therapy (cont.)

All of the following are advantages of incentive spirometry, except? Potential absence of or improvement in signs of atelectasis It is only needs to be performed once per day IS devices provide visual cues to the patient when a desired inspiratory volume of flow is reached. Has proved to be effective in high-risk patients Answer: B

Lung Expansion Therapy (cont.) Intermittent Positive Pressure Breathing (IPPB) Uses positive airway pressure to expand lung Treatments last 15 to 20 minutes Exhalation is passive

IPPB

Lung Expansion Therapy (cont.) Indications for IPPB Patient with atelectasis not responsive to other modalities such as IS Patient at high risk for atelectasis who cannot perform IS

Active, untreated tuberculosis Nausea Singultus All of the following clinical situations are contraindications of IPPB therapy except: Active, untreated tuberculosis Nausea Singultus Inability to take a deep-breath Answer: D

Lung Expansion Therapy (cont.)

Lung Expansion Therapy (cont.)

Lung Expansion Therapy (cont.) Administration of IPPB Preliminary planning Therapeutic outcomes set Evaluate alternatives Baseline assessment of patient

Lung Expansion Therapy (cont.)

Lung Expansion Therapy (cont.) Administration of IPPB (cont.) Implementation Equipment preparation Patient orientation Patient positioning Adjusting parameters Flow pressure

Lung Expansion Therapy (cont.) Positive airway pressure therapy (PAP) Definition PEP EPAP CPAP

Positive Airway Pressure Therapy

Lung Expansion Therapy (cont.) Indications Treatment of atelectasis Treatment of cardiogenic pulmonary edema Contraindications Hemodynamic instability Patient with hypoventilation

Lung Expansion Therapy (cont.) Hazards & complications Barotrauma Hypoventilation Gastric distention Vomiting & aspiration

PAP Equipment

Vomiting and aspiration All of the following are complications of lung expansion therapy, except? Barotrauma Increased FRC Gastric distention Vomiting and aspiration Answer: B

Lung Expansion Therapy (cont.) Monitoring & troubleshooting with positive airway pressure (PAP) therapies Most common problem with PAP therapies is system leaks Patient must be monitored for hypoventilation & elevated PCO2 Inspiratory flow must be adequate

Selecting an Approach Chose modality that is safest, simplest, & most effective RT should evaluate the following before choosing a specific modality: Level of patient cooperation Amount of pulmonary secretions Patient’s spontaneous vital capacity

Selecting an Approach (cont.)