pap positive airway pressure (pap) adjuncts are used to mobilize secretions and treat atelectasis...
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PAP Positive airway pressure (PAP) adjuncts are used to mobilize secretions and treat atelectasis and include continuous positive airway pressure (CPAP) positive expiratory pressure (PEP) expiratory positive airway pressure (EPAP). Cough or other airway clearance techniques are essential components of PAP therapy when the therapy is intended to mobilize secretions Slide 2 PAP: CPAP The patient breathes from a pressurized circuit against a threshold resistor (water-column, weighted, or spring loaded) that maintains consistent preset airway pressures from 5 to 20 cm H2O during both inspiration and expiration (By strict definition, CPAP is any level of above- atmospheric pressure.) CPAP requires a gas flow to the airway during inspiration that is sufficient to maintain the desired positive airway pressure. Slide 3 PAP: CPAP Types of threshold resistors: all of these valves operate on the principle that the level of PAP generated within the circuit depends on the amount of resistance that must be overcome to allow gas to exit the exhalation valve. They provide predictable, quantifiable, and constant force during expiration that is independent of the flow achieved by the patient during exhalation Slide 4 PAP: CPAP Underwater seal resistor: expiratory port of the circuit is submerged under a column of water, the level of CPAP is determined by the height of the column Weighted-ball resistor: consists of a steel ball placed over a calibrated orifice, which is attached directly above the expiratory port of the circuit Slide 5 PAP: CPAP Spring-loaded: rely on a spring to hold a disc or diaphragm down over the expiratory port of the circuit. Magnetic valve resistors contain a bar magnet that attracts a ferromagnetic disc seated on the expiratory port of the circuit the amount of pressure required to separate the disc from the magnets is determined be the distance between them. Slide 6 PAP: PEP The patient exhales against a fixed-orifice resistor, generating pressures during expiration that usually range from 10 to 20 cm H2O PEP does not require a pressurized external gas source. The amount of PEP varies with the size of the orifice and the level of expiratory flow produced by the patient. The smaller the orifice the greater the pressure. Slide 7 PAP: PEP Thus the patient must be encourage to generated a flow high enough to maintain expiratory pressure at 10-20 mm H2O Ideal I:E of 1:3 or 1:4 The patient should perform 10-20 breaths through the device and then perform 2-3 huff breath coughs This should be repeated 5-10 times during a 15-20 minute session Slide 8 PAP: EPAP The patient exhales against a threshold resistor, generating preset pressures of 10 to 20 cm H2O (similar to CPAP expiration) EPAP does not require a pressurized external gas source. EPAP utilizing threshold resistors does not produce the same mechanical or physiologic effects that PEP does when a fixed orifice resistor is used. Further study is necessary to determine how these differences affect clinical outcome. Slide 9 IPPB, IPV, PEEP/CPAP and BIPAP October 1 & 8 Slide 10 INTERMITTENT POSITIVE PRESSURE BREATHING Slide 11 IPPB Intermittent Positive Pressure Breathing (IPPB) is a short-term breathing treatment where increased breathing pressures are delivered via ventilator to help treat atelectasis, clear secretions or deliver aerosolized medications IPPB can include pressure- and time-limited, as well as pressure, time, and flow-cycled ventilation. IPPB may be delivered to artificial airways and non-intubated patients. Slide 12 IPPB INDICATIONS: The need to improve lung expansion The presence of clinically significant pulmonary atelectasis when other forms of therapy have been unsuccessful (incentive spirometry, chest physiotherapy, deep breathing exercises, positive airway pressure) or the patient cannot cooperate Slide 13 IPPB Inability to clear secretions adequately because of pathology that severely limits the ability to ventilate or cough effectively and failure to respond to other modes of treatment The need for short-term ventilatory support for patients who are hypoventilating as an alternative to tracheal intubation and continuous mechanical ventilation Slide 14 IPPB The need to deliver aerosol medication. IPPB may be used to deliver aerosol medications to patients with fatigue as a result of ventilatory muscle weakness (eg, failure to wean from mechanical ventilation, neuromuscular disease, kyphoscoliosis, spinal injury) or chronic conditions in which intermittent ventilatory support is indicated (eg, ventilatory support for home care patients and the more recent use of nasal IPPV for respiratory insuff iciency) Slide 15 IPPB Assessment of need: Presence of significant atelectasis Reduced pulmonary function, reduced VC, VT Neuromuscular disorders Prevention of atelectasis Assessment of Outcome: Minimum VT of at least 1/3 of predicted IC Increase in FEV1 More effective cough, CXR improved, BS improved Slide 16 IPPB CONTRAINDICATIONS: There are several clinical situations in which IPPB should not be used. With the exception of untreated tension pneumothorax, most of these contraindications are relative: Increased ICP >15 mmHg Hemodynamically unstable Recent Facial, oral or skull surgery Tracheoesphogeal fistula Slide 17 IPPB Recent Espohageal surgery Active hemoptysis Nausea Air swallowing Active TB Blebs Singulation (hiccups) Slide 18 IPPB Hazards/complications Increased RAW and WOB Barotrauma/pneumothorax Nosocomial infection Hypocarbia Hemoptysis Hyperoxia when O2 used as gas source Gastric distension Impaction of secretions Slide 19 IPPB Impendance of venous return Air trapping Limitations of Device Effects are short lived, lasting an hour Delivery of medication is ineffective due to low delivering flow through nebulizer Patient dependent IPPB equipment is labor intensive Limited portability Slide 20 IPPB IPPB is pneumatically powered Patient triggered and pressure cycled You set: Pressure limit, flow, sensitivity Slide 21 IPPB Given through a mouth piece or mask Varying types, BIRD Mark series, PB Slide 22 IPPB Setup Pressure manometer. Negative should not be more than -2, if it is adjust your sensitivity Flow rate adjustment. Sensitivity adjustment Pressure adjustment Air mix, either 100% if pushed in or 80% pulled out Slide 23 IPPB How the machine works: In IPPB, we set a driving pressure [PIP] on the machine, and when the patient triggers the machine by decreasing the pressure in the line, gas starts to move down the tube into the mouth and airways. When the preset PIP is reached, the gas flow shuts down immediately. The inspiratory phase has cycled off. Slide 24 IPPB: Pressure Pressure set on the IPPB will determine the pressure limit Pressure is directly related to volume, increasing the pressure limit will increase the volume in the lung Measure VT with Venti-comp bag Slide 25 IPPB Pressure Pressure is typically started low, around 10-15 cmH2O and increased to achieve desired VT. Remember, IPPB is hyperinflation therapy, the goal is to exceed normal tidal volume ranges. Once the machine is triggered on by the patient and pressure is reached (seen on manometer) the machine cycles off Too much pressure can cause barotrauma Slide 26 IPPB Flow The flow setting on the IPPB dictates how fast the pressure limit is reached High flow = low inspiratory time Low flow = high inspiratory time Start low around 5-10 L and increase depending on the desired inspiratory time Normal times should be around 1-1.5 seconds for inspiration Slide 27 IPPB Flow To decrease the inspiratory time we need to increase the flow rate To increase the inspiratory time, we need to decrease the flow rate If we increase the PIP to increase the VT, sometimes the inspiratory time is too long and we have to increase the flow rate. Remember that really fast flow rates will only cause increased RAW, so keep the inspiratory time between 1-1.5 seconds for adults. Remember that the air mix mode involves air entrainment so the flow rate will be changed by changing the Fi02 Slide 28 IPPB Sensitivity The sensitivity on the IPPB machine is manipulated by the dial on the left hand side of the machine. Increasing the Inspiratory Effort dial will make the machine less sensitive to the patients inspiratory trigger. This increases the magnetic pull inside the sub atmospheric side of the,IPPB bird machine making it more difficult for the patient to trigger the machine on, increasing WOB Slide 29 IPPB Sensitivity Decreasing the patient effort dial will make the machine more sensitive to the patients inspiration. This may cause auto-triggering if it is set too low. Decreasing this dial creates less magnetic pull on the diaphragm in the middle of the machine Slide 30 IPPB FIO2 If you do not wish to deliver high FIO2 to the patient during the IPPB procedure, attach the machine to a air outlet, otherwise the only two FIO2 available are 100% or 80% with air dilution NOTE: on the IPPB machine there is a APNEA- expiratory time setting, do not turn this on unless you want a back up rate. Slide 31 Breathing while on IPPB Remember, this is not ventilation. IPPB is a sustained maximal inspiration just like IS, so we do not need to breathe much faster than 6-8 bpm. The patient may breathe faster, but he can do so off the IPPB. Rapid RR on the IPPB will increase chances of impeding venous return to the heart, reducing the amount of blood in the heart which would cause the patient to become tachycardiac in order the keep the same cardiac output. Slide 32 Breathing while on IPPB If the patient becomes light headed, dizzy or feels tingling in their fingers during the procedure- STOP and allow patient to rest, this is caused by the quick elimination of CO2 Rapid RR will encourage air trapping, particularly in persons with increased RAW and wheezingwe need plenty of time to exhalation Slide 33 Breat