Lung Expansion Revision

8/3/2019 Lung Expansion Revision

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LUNG EXPANSION THERAPY


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Objectives

The focus of this module is on re

expanding collapsed alveoli. Collapse

of lung tissue makes it more difficultfor oxygen to diffuse into the blood.

Therefore, reexpanding collapsed

lung tissue is a high priority.


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The single lesson in this module

addresses:The different causes of alveolar

collapse and the lung expansion

therapies such as incentivespirometry(IS), intermittent positive

pressure breathing (IPPB), and

continuous positive airway pressure(CPAP) used to reinflate the lungs.


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LUNG EXPANSION THERAPY

A group of medical treatment

modalities designed to prevent

and/or treat pulmonary atelectasisand associated problems


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Atelectasis refers to the collapse of alveoli.

Collapse of an entire lobe is called lobar

atelectasis.The table describes the threemajor ways atelectasis occurs.

The terms resorption atelectasis,

reabsorption atelectasis, and absorptionatelectasis all refer to gas being absorbed

from the alveolus into the bloodstream. This

alveolar collapse occurs: When the alveolus is obstructed

More quickly with a higher


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Type Mechanism example

Resorption atelectasis An obstructed airway =

allows gas in the alveoli to

be absorbed into the

bloodstream

Blocked airway caused by:

Tumor in airway

Mucus plug

Passive atelectasis Shallow breathing - leads

to collapsed alveoli.

Space - occupying lesion

causes nearby alveoli to

collapse

Shallow breathing

Postoperative pain from

thoracic or upper

abdominal surgery

ObesityNeuromuscular weakness

Sedation

Lung compression

Pneumothorax

Pleural effusionLung mass

Adhesive atelectasis Low levels of surfactant Respiratory distress

syndrome (infants)


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COMPRESION ATELECTASIS


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High risk of atelectasis Low risk of atelectasi

55-year-old man who had coronary

artery bypass surgery

45-year-old man who had knee

arthroscopy

Patient with 25 pack-year smoking

history and inguinal hernia repair

Healthy 25-year-old with wrist

fracture

82-year-old confused woman with a

broken hip

15-year-old girl with severedevelopmental delay and fever


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Post-op thoracic or abdominal

surgery patients

Any heavily sedated patient

Patients who have

neuromuscular diseases

These diseases may

weaken breathing

muscles

Patients who are unable toambulate

Patients with chest trauma or

chest wall injury


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CLINICAL SIGN OF ATELECTASIS In acute atelectasis in which there is sudden

obstruction of the bronchus, there may bedyspnea and cyanosis, elevation oftemperature, a drop in blood pressure, orshock.

In the chronic form, the patient may experienceno symptoms other than gradually developingdyspnea and weakness.

X-ray examination may show a shadow in the

area of collapse. If an entire lobe is collapsed,the x-ray will show the trachea, heart, andmediastinum deviated toward the collapsedarea, with the diaphragm elevated on that side.
http://www.healthscout.com/ency/68/440/main.htmlhttp://www.healthscout.com/ency/68/440/main.html


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Bronchoscopy may be included in diagnostic

procedures to rule out an obstructing

neoplasm or a foreign body if the cause isunknown.

Other characteristics include diminished

breath sounds, fever, and increasing dyspnea(shortness of breath).

Diagnosis of Atelectasis

Atelectasis is diagnosed by clinical exam, closemonitoring of a post-operative clinical course,

and x-ray.
http://www.healthscout.com/ency/68/440/main.htmlhttp://www.healthscout.com/ency/68/440/main.html


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PLEURAL EFFUSION


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Sustain Maximal Inspiration

Breathing deeply is the easiest way to increase

lung volumes


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Increasing the gas flow directly to the alveolus

Inflating nearby alveoli through pores of Kohn

A sustained maximal inspiration (SMI) is a deep

breath followed by a breath-hold. Patients

should also be encouraged to cough and

remove any mucus obstructing the airway.


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Preparation:

Pain control (if appropriate):

Patient should use patient-controlled analgesia(PCA) prior to treatment.


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Hold a pillow over surgical incision (if present)

called splinting.


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Position patient to make it easier for

diaphragm to descend:

Elevate head of bed (HOB).

Dangle feet.


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Teach proper breathing with diaphragm:

Diaphragm contracts and descends.

Abdomen should move outward on inspiration: Coach patient to hold hand over abdomen to monitor

movement.

Assess bilateral chest wall movement.

Ask patient to inspire maximally:

Use a slow to moderate flow rate:

Decreases pain (if present)

Less turbulence in flow pattern


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Hold breath 5 to 10 seconds at the end of

inspiration: Maximizes time for air to inflate collapsed alveoli

Exhale normally.

Repeat 6 to 10 times each hour.


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Lung Expansion Therapy include: a variety of

respiratory care modalities designed to

increase lung volume Incentive Spirometry - IS therapy

IPPB - Intermittent Positive Pressure

Breathing

PEPPositive Expiratory Pressure

EPAPExpiratory positive airway Pressure

CPAP - Continuous Positive Airway Pressure


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INCENTIVE SPIROMETRY

Used primarily as a preventative or

prophylactic treatment

Patient are encouraged to take slow - deep

inspirations ten times every hour

Patients are taught to perform 5-10 second

breath holds at maximal inhalation for

each of the 10 hourly breaths


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enhances lung expansion via spontaneous

and sustain- is a device that provides the patient with

visual feedback. Device that measures the

breath volume. A- The goal of IS therapy is to prevent

atelectasis if the patient @ high risk of

athelectasis- reverse athelectasis if the patient has a

symptom of athelectasis


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Incentive spirometry will not be successful if thepatient is unconscious or has a vital capacity


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Prior to Teaching I.S. do the following:

Check the chart for;

Order; Admitting Dx; evidence of any recentsurgery (when?; type?); evidence of any previous

pulmonary problems (COPD; asthma?); Chest X-

ray reports

At the bedside check for;

mental status; ability to comprehend; pain level;

evidence of any pulmonary problems (tachypnea

&/or S.O.B.?)


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Advantages of I.S. Therapy

Patients can self-administer as often as they like

Relatively easy to learn and perform


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Commonly use and IS are not appropriate to

the pt

Very rare side effects

Inexpensive way of preventing pulmonary

complications

Patient is not alert or cannot follow instructions

Patient cannot hold mouthpiece in their mouth

Patient has a large atelectasis that must be

treated with more aggressive measures Patient cannot create a large enough breath for

I.S. to be of any real value


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What to Focus on During I.S. Instruction

What is I.S. Why is the patient going to learn how to

perform it

How often should the patient perform it Does the patient have any questions


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Evaluate need for pain medication (if needed).

Assess breath sounds and vital signs.

Establish treatment goals. Position patient for maximal inspiration.

Maximally inhale.

Hold breath 5 to 10 seconds.

Exhale slowly.

Repeat 6 to 10 times.

Ask patient to cough.

Reassess breath sounds and vital signs. Leave IS within reach of patient.

Record treatment in medical record.


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Types of I.S. Devices

Volume Oriented devices Actually measure & display the amount of

air patient inhaled


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Types of I.S. Devices

Flow Oriented devices

Only display inspiratory flowrate and may

attempt to estimate amount of air inhaled


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INTERMITTENT POSITIVE PRESSURE

BREATHS (IPPB)

as Method of Enhancing Lung Expansion

Definition - Lung expansion therapy utilizing positive

airway pressure for periods of 15 - 25 minutes to

enhance resting lung ventilation by increasing thepatients tidal volume (Vt)

How Positive Pressure Ventilation Differs from Normal

In normal breathing, inspiratory pressures arenegative while expiratory pressure are positive

In IPPB, both inspiratory pressures & expiratory

pressure are positive


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Indications For IPPB

Patient has an atelectasis that is not

responding to I.S. therapy Patient cannot perform I.S. therapy

This may also be a problem with IPPB!!

Poor cough effort & secretion clearance dueto inability to take a deep breath

Short term ventilatory support when patientis hypercapnic

Enhancement of aerosol medication deliveryin patient unable to take a deep breath


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Contraindications to IPPB

Untreated pneumothorax

High intracranial pressure (>15 mm Hg)

Active hemoptysis

Radiographic evidence of a bleb Nausea

Tracheo-esophagel fistula

Recent esophageal surgery


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Hazards & Complications of IPPB

Barotrauma (pneumothorax)

Hyperventilation (dizziness)

Gastric distension (secondary to air

swallowing)

Decrease in venous return (possible drop in

B.P.)

Increased airway resistance May actually cause bronchospasm in some

patients!


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Monitoring the IPPB Treatment

What is the pulse & respiratory rate prior to

treatment? What are the patients breath sounds; their

color; respiratory effort; mental state - prior

to the Tx? What is the patients SpO2 or peakflow before

the treatment (if giving bronchodilators)


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Equipment Needed for IPPB

IPPB Ventilator - Bennett AP-5 series ventilator OR Bird Mark

series 7 ventilator

IPPB tubing circuit

Universal disposable circuits now used

Additional equipment possibly needed;

Mouthseal & noseclips for patients who cannot

use mouthpiece Mask (if mouthseal is not available)

Connector for using circuit with trach patient


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IPPB Bird Circuit

Main Flow Tube

Exhalation Valve

Drive Line

Manifold

Nebulizer

Exhalation

Valve

Holder

Reservoir

Tube

Mouthpiece


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inhalation


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exhalation


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ElectricallyPowered

Pressurelimited

Only patient

triggered

AP- 4

AP - 5


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IPPB Instruction to the pt

Explain what is IPPB

Why is the patient going to be receiving IPPB

treatments

How long is each treatment & how often will

they receive it

What should they do during the treatment

Any questions they have of you


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What SHOULD the patient do during IPPB?

Patient starts their breath; the machine

cycles on Patient relaxes and lets the machine fill their

lungs

Patient should NOT be actively breathingafter the machine cycles (turns on)

Patient will exhale normally in a relaxed way

through the mouth when machine endsinspiration (pre-set pressure is reached)


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What should the therapist emphasize during

the treatment?

Make sure patients keep lips sealed tightaround the mouthpiece

Coach patient to not actively breath

Relax and let the machine fill your lungs!

Make sure patient does not breath too

rapidly during treatment

This will cause dizziness secondary to

hyperventilation


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Key Aspects & Terms Associated with IPPBventilators

Patient initiates the breath and machine isable to detect the patients effort and thenstarts delivering gas into the mouthpiece

The ability of machine to detect the patientsneed for a breath is called sensitivity

Sensitivity should be set so that machine willbegin breath at a pressure that is 1 or 2

cmH2O pressure below zero (or -1 to -2cmH2O pressure)


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These machines are pressure cycled

This means that inspiration ends when a presetpressure is reached in the circuit

Preset pressure is set by the therapist

Typical pressure ranges (15 - 25 cmH2O) Pressures higher than 25 associated with air

swallowing particularly with mouthseal ormask treatments

Pressures less than 15 may be insufficient toincrease the tidal volume (Vt)


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Characteristics of Pressure Cycling

Any leak in the circuit or in the patient will cause the

machine to not end inspiration (cycle off) Patient can easily end the breath by

blowing back into the mouthpiece

putting their tongue over the mouthpiece

Pressure cycled machine can NOT guaranteed to deliverany specific volume to the patient

Volume delivered is based upon;

the patients ability to relax and let the machine deliverthe breath

the pressure level set by the therapist the higher the pressure level set - the greater the volume

delivered to the patient (ideally)


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POSITIVE AIRWAY PRESSURE

Positive Pressure creating lung expansion

approaches to positive airway pressure therapy:

(PEP) positive expiratory pressure

(EPAP) expiratory positive airway pressure

(CPAP) continuous positive airway pressure

INDICATIONS f P iti i


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INDICATIONS for Positive airway

pressure tx

To reduce air trapping in asthma and COPD

To prevent or reverse atelectasis

To aid and mobilization or retain secretions

To optimize bronchodilator

P t ti l C t i di ti t it


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Potential Contraindication to positve

airway pressure tx

Pt unable to tolerate an increased work ofbreathing

Intracranial pressure > 20 mmHg

Hemodynamic instabilityRecent facial, oral, skull surgery or trauma 4

Acute sinusitis

EpistaxisEsophageal surgery


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Active hemoptysis

Nausea

Middle air phatology, e.g.,tympanic membrane

rupture

Untreated pneumothorax


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Hazards and complications of positive airwaypressure tx

Due to increase pressure:Pulmonary barotrauma

increased intracranial pressure

decreased venous return

gastric distention

Due to the apparatus

Increased work of breathing (resistor)

Vomiting/aspiration (gastric distention +mask)


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Claustrophobia (mask)

Skin break down and discomfort (mask)

Epistaxis


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PEP Tx (possitive expiratory pressure)

a form fitting face mask, a one way T-valveassembly, a p ressure manometer, and an

adjustable flow resistor


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1. Expiratory resistor (4 settings)

2. One-way valves

3. Manometer

4. Mask

5. Mouthpiece

6. Nebulizer (optional)

7. Aerosol tubing (optional)

Picture will be given to hand out


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Threshold PEP is used for

airway clearance,

bronchial hygiene, oras an alternative to chest physical therapy.

Threshold PEP incorporates a flow-independentone-way valve to ensure consistent resistance

with adjustable specific pressure settings(in cm H20) which are set by the healthcareprofessional. When patients exhale throughThreshold PEP, the resistive load creates positive

pressure that helps open the airways and allowsmucus to be expelled during "huff" coughing(forced expiratory technique).


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The pt should be seated comfortably with elbowresisting on a flat surface

The mask is place snugly over the nose and mouthUsing diaphragmatic breathing, the pt inhales a

volume 2-3 times larger than the normal tidalvolume or Vt the slowly exhales not (forcely) to

the FRC through the flow resistor, keeping thepositive expiratory pressure between 10 and 20cm H2O and repeated 10-20 breaths, @ whichtime the mask is removed and the pt. perform 2-

3 huff coughs this sequence repeated 4-6times for each PEP tx session with intervals 10-20mins. And vary from twice 4 x daily

EPAP (expiratory positive pressure


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EPAP (expiratory positive pressure

airway pressure)

Similar to PEP except the treshold resistorreplaces the flow resistor

The pressure generated by a treshold

resistor is independent of flow, usuallybetween 10-20 cm H20.

For a person on a ventilator, this would referto positive airway pressure being providedwhile they breathe out.


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can also be used to describe a device used to

treat sleep apnea called Provent. According to

the manufacturer, Provent uses a one-wayvalve that is placed over the nostrils at night

time.

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http://ent.about.com/od/entdisorderssu/a/sleep_apnea.htmhttp://ent.about.com/od/entdisorderssu/a/sleep_apnea.htm


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EPAP does not require a source of pressurized

gas

Become positive during inspirationpressure changes in spontaneous and

positive pressure breathing


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Aproaches to EPAP

The simplest approach is to use the sameequipment as use for PEP tx, but replace the flowfor resistor

this tyope of system requires no pressurized

gasA pressurized gas from a flow meter

A. Flows continuously into a large volume aerosol

generatorB. Into the inspiratory limb of the circuit attache tothe T-piece in the inspiratory limb of the circuit


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C. Is an aerosol reservoil

D. Open to the atmosphere this reservoir

provides extra volume if the pt inspiratoryflow

exceeds that of the system

E. Pt breaths in and out through a mask attach

to a T- piece

F. The expiratory limb of the circuit is connected

to a treshold resistor (G) in this case a water

column.


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EPAP pressure can be varied by adding orremoving water from this column


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TRESHOLD RESISTOR FOR CPAP/EPAP

Underwater columns

Spring-loaded diaphragms or disks

Gravity- weighted balls

Balloons valves with preset pressure

Reverse venturi systems

Electromechanical valves

CLINICAL FINDINGS INDICATING FOR POSSTIVE


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CLINICAL FINDINGS INDICATING FOR POSSTIVE

AIRWAY PRESSURE TX TO TREAT ATELECTASIS

Change in breath sounds consisted with

atelectasis

Change in vital signs increase in breathing

rate tachycardia and fever

Abnormal chest x-ray indicating with

atelectasis, mucus plugging or infiltrates

Deterioration in arterial oxygenation or Spo2

FLUTTER VALVE


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FLUTTER VALVE

The Flutter Valve (Scandipharm products) is a

device to deliver PEP therapy in a slightly

different approach. The device consists of a

mouthpiece connected to a cylinder in whicha stainless steel ball rests in a cone shaped

valve. The patient exhales through the

cylinder and causes the ball to move up anddown during the exhalation.


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Purpose:

To provide protocol driven respiratory therapyby incorporating the flutter valve to facilitate

the mobilization of secretions in patients with

chronic high volume sputum production andin patients

with an ineffective cough with evidence ofretained secretions and/or atelectasis.

The effect is threefold:


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The effect is threefold:

first, to vibrate the airways and thus,

facilitate movement of mucus; second, to increase endobronchial

pressure to avoid air trapping and

third, to accelerate expiratory airflow tofacilitate the upward movement of

mucus.

l


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Policy:

1) Flutter Valve Protocol will be initiated on

patients by a written order from the physician.Flutter

Valve may be ordered as:

Flutter Valve Therapy RT Protocol

RT Consult

Flutter Valve may be used in conjunction with:

- Chest Physical Therapy

- Autogenic Drainag

Pulmonary Considerations:

C i di i


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Contraindications:

Inability to comprehend instruction or performbreathing maneuvers.

Acute dyspnea in which the patient cannot breathhold or control expiratory airflow.

Patient with untreated pneumothorax.

Immediate post-op nasal, oral, or mouth surgery. Patients less than four years of age, unless they can

demonstrate the attention span and

discipline to learn the breathing technique

- active hemoptysisright sided heart failure

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Hazards/Complications:

Acute Hypotension during procedure

Pulmonary Hemorrhage

Vomiting and Aspiration

Bronchospasm

Dysrhythmias

Hypoxemi


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Acute Care: Patients with excessive mucus production having

difficulty expectorating and do not have an artificialairway in place.

Subacute /Home Care: Again, the above statement applies to the home

care/subacute setting. Another group of patients

that may significantly benefit from Flutter therapyare those with cystic fibrosis. Traditional therapy ofpostural drainage and chest percussion can take overan hour to complete. Compliance with this therapybecomes difficult, especially with the teenage

population. Flutter therapy has been proven to atleast equal more traditional forms of therapy inmuch less time.


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Limitations: The major limitation is patient

cooperation and ability to follow directions.

Assessment of Positive Outcomes: Increased


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fsputum production, patient's subjectiveresponse to therapy, improvement in chest x-

ray, ABG's, and/or SaO2. Tips: The amount of tilt of the Flutter is

important. Initally, the mouthpiece should behorizontal to the floor. Then the cone is tilted up

or down to achieve maxiaml "flutter" effect. Theway this can be assessed is to place your handson the patient's back and chest. When maximalfluttering is achieved, you will be able to fell the

vibrations. The patient may need several sessionsto establish the correct tilt.


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In the home care setting, patients should be

instructed and monitored on appropriate

infection control. After each session, thedevice should be disassembled, rinsed and

dried. Every 2 days, patients should

disassemble and clean the device with a mildsoap or detergent, rinse, and dry. At regular

intervals, the device should be disassembled

and soak their cleaned components in a

solution of 1 part alcohol to 3 parts tap water

for 15 minutes- then rinsed and dried

Vibratory Positive Expiratory Pressure


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Vibratory Positive Expiratory Pressure

System

S


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BENEFITS

Can accommodate virtually any patients lungcapacity.

Allows inhalation and exhalation withoutremoving from mouth.

May be used with mask or mouthpiece Nebulizer

Can accommodate virtually any patient's lungcapacity. Reproducible therapies.

Use in any position-patient is free to sit, stand orrecline

PROCEDURE


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PROCEDURE

1. Ask the patient to slowly inhale beyond anormal breath (but not maximally).(Have the patient hold his/her breath for 2 to 3seconds. )

2. Have the patient place the flutter valve in themouth, keeping cheeks stiff and adjusting thetilt of the cylinder.

( Exhale through the flutter at a fairly fast flowrate, exhaling past normal exhalation (but notmaximally).


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3. Repeat procedure for 5 to 10 breaths.

Stage 2 (Eliminating Mucus):


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1. Have the patient slowly inhale to a maximalinspiration.

2. Hold breath for 2 to 3 seconds.

3. Place Flutter valve in mouth, adjusting tilt andkeeping cheeks stiff.

4. Exhale forcefully through the flutter ascompletely as possible.

5. Repeat 1 to 2 times.

6. Initiate cough or huff maneuver.

7. Repeat procedure (Stage 1 and 2) until nofurther mucus production is obtained.

lCONTINUOUS POSITIVE AIRWAY PRESSURE


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CONTINUOUS POSITIVE AIRWAY PRESSURE

(CPAP)

A simple approach which maintains somepositive pressure in the airway at the end of

exhalation

Net effect of CPAP is that FRC is increased There is a high correlation between

improvement of atelectasis and the patient

having a higher than normal FRC

Contraindications to CPAP


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If blood pressure is very low

Diastolic of


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Hazards of the Use of CPAP

Barotrauma (pneumothorax)

Gastric distension

Air-trapping

Decrease in BP Can be very uncomfortable to the face of

patient using mask CPAP

Beneficial Effects of CPAP


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Beneficial Effects of CPAP

Recruitment of collapsed alveoli

The work of breathing is decreased as lungcompliance (stretchability) improves

Improvement of gas distribution

Improvement in secretion removal

Indications for Use of CPAP

Treatment of post-operative atelectasis

Should be used continuously

Has been used in the treatment of cardiogenicpulmonary edema

CPAP Accomplish?


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CPAP Accomplish?

Increases the FRC by increasing the amount

of air in the chest at the end of exhalation

The net effect of increasing FRC is to;

Re-open any atelectatic areas

Improve any hypoxemia that may be

resulting from the atelectasis

CPAP is also used to treat sleep apnea

secondary to upper airway obstruction

Lung Expansion Revision

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