Unit 3.2 case studies IS therapy By Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

Your patient is Mr. Thomas who is a 48 year old WM who is going to surgery in the morning. He will having open heart surgery for a coronary artery bypass. You have an order to perform a pre-op Incentive Spirometry. You:

answer Agree. This Rx is needed because he will be having a surgery that involves an incision into the chest muscles. He will have problem taking a deep breath in. You like doing this before surgery because he will be alert and he will easily get the goal you select for him which will help him understand why he needs this TX tomorrow.

You go to his chart to find the information you need to do this therapy. You want to see the following:

answer His height His vital signs, to establish a baseline X-ray report for presence of atelectasis His prior medical history, to find: – any possible contraindications to IS. –More indications for IS –Special problems he might have

Why do you need his height?

answer To calculate his IBW. You see that he is 6 foot tall. You calculate his minimal goal at ----ml and his maximal goal at ---

answer 6 feet = 72 inches For the first 60 inches, he gets 105 ml and we add 6 inches per each inch over that (12 x 6) = = 177 IBW in pounds. We convert to kg by dividing by /2.2 = 80.4 kg is his IBW He needs at least 12 mL/kg IBW to cough so the minimum goal is 965 mL Max is 45 ml/Kg or 3.6 liters

You see, on his x-ray, that Mr. Harris has a normal chest x-ray prior to surgery. You see that he has no history of COPD, nor does he have any neuromuscular problem. You can expect:

answer That he will do quite well with IS treatments. He has no contraindications

Mr. Harris goes to surgery and when he gets out, you meet him in the recovery room. He is asleep and hard to arouse. His breath sounds are distant in the bases and you hear scattered rhonchi in the upper lobes. Because he isn’t awake yet you:

answer Leave the IS at the bedside and return in an hour or two to start the IS. He is still very sedated, but the breath sounds tell you that you need to stay on top of this TX.

You return in an hour and the patient is now groggy. His breath sounds are unchanged and his respiratory rate is 26bpm and shallow. His heart rate is 112 bpm. You start the IS and his first breath only goes to 500 ml and the indicator drops immediately. You:

answer Encourage him to do it again, but this time hold the breath for at least 3-5 seconds. Make him repeat this sustained maximal inspiration at least 10 times.

How often should Mr. Harris repeat this IS?

answer He should do an IS every 1-2 hours he is awake

After he does 6 breaths at mL, Mr. Harris says he cannot do anymore. He refuses to do another breath. You:

answer You get him to take another deep breath by asking him to breath for you while you listen to his chest. Ask him to cough

Mr. Harris just clears his throat when you asked him to cough, so you:

answer Ask him to take the breath as deeply as he did on the IS, hold it for 3-5 seconds then cough again.

He coughs. What do you note now?

answer Reassess his breath sounds after the treatment. He should have decreased rhonchi after the cough. Reassess his vital signs. His heart rate and respiratory rate should be the same as before Assess the color and thickness of the sputum he expectorated

Case study # 2 Mrs. Hubert is a 45 year old BF with a history of a chronic paraplegia secondary to a spinal cord injury as a teenager. She presents in the ER with increased respiratory rate at 28 bpm, and increased heart rate at 125 bpm. How else would you assess this patient?

answer You listen to her breath sounds. You look at her chest x-ray You do a pulse oximetry to rule out hypoxemia

You hear diminished breath sounds bilaterally in the middle and lower lobes and rhonchi and crackles in the upper lobes. On her chest film you see the entire LLL is has atelectasis and there are infiltrates in the rest of the right and left lungs You want to assess what next?

answer Because she has atelectasis, you would like to measure her inspiratory capacity with the IS to see if she can take a deep breath.

On the IS, her IC is 500 ml. Before you make a decision what other information do you need?

answer You need her IBW. It is 58 kg.

Would IS be helpful for this patient?

answer No, for several reasons. – she needs to get at least 12 ml/Kg 700 ml in order for IS to prevent atelectasis & she can’t even get 10 ml/kg –IS is to prevent post-op atelectasis and she already has atelectasis –She doesn’t have post-op atelectasis. She most likely has a pneumonia secondary to her chronic hypoventilation due to her paralysis

What can you do for this patient?

answer Consider starting her on IPPB to treat the atelectasis Complete assessing her by pulse oximetry and inspection for the presence of hypoxemia and treat her with supplementary 02 if that is the case. Recommend sputum cultures, so she can be started on antibiotics