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Causes & Types of Atelectasis

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Causes of Atelectasis from postoperative or bedridden patients

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Gas absorption atelectasis

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Resulting from the absorption of O2 from obstructed or partially obstructed alveoli with high O2 concentrations

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Compression atelectasis

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Collapse of a part of the lung as a result of an external force compressing the lung

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Gas absorption atelectasis can occur when...

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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

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Compression atelectasis is caused by

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persistent breathing with small tidal volumes and/or certain types of restrictive chest-wall disorders

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Factors Associated with Causing Atelectasis

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Atelectasis can occur in any patient who cannot or does not take a deep breath periodically and bedridden patients

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Pts who have difficulty include:

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

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Clinical Sign of Atelectasis

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History of recent major surgery Tachypnea Fine, late-inspiratory crackles (pop) Bronchial or diminished breath sounds Tachycardia Increased density & signs of volume loss on chest radiograph The physical signs of atelectasis may be absent or very subtle if the patient has minimal atelectasis Chronic lung disease or cigarette smoking or both provides additional evidence that the patient is prone to respiratory complications after surgery or prolonged bed rest

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Lung Expansion Therapy

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All modes of lung expansion therapy increase lung volume by increasing transpulmonary pressure gradient (PL) The difference between alveolar pressure (Palv) and pleural pressure (Ppl) *𝑃_𝐿=𝑃𝑎𝑙𝑣−𝑃𝑝𝑙(

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PL gradient can be increased by either

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1. Decreasing the surrounding Ppl 2. Increasing the Palv

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Positive pressure to the lungs in PL gradient by

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increasing the pressure inside the lung

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Goal of lung expansion therapy

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should be to implement a plan that provides an effective strategy in the most effective manner

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2 issues related to efficiency of Lung Expansion Therapy

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Time and equipment

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Incentive Spirometry Purpose

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The purpose is to guide the patient to take a sustained maximal inspiratory effort resulting in a decrease in Ppl and maintain the patency of airways at risk for closure

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Incentive Spirometry

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Designed to mimic natural sighing by encouraging patients to take slow, deep breaths Has shown to be efficient and effective against postoperative atelectasis in high risk patients

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Incentive Spirometry is a

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basic maneuver is sustained maximal inspiration (SMI)

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Incentive Spirometry

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Slow, deep inhalation from functional residual capacity (FRC) up to ideally total lung capacity (TLC), followed by a 5 to 10 second breath hold

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Successful Incentive Spirometry includes

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-effective teaching -set an initial goal that requires some effort -instruct the patient on taking a slow deep breath as big as they can and -hold at the end for 5 to 10 seconds. -Always demonstrate the breath you want

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IPPB

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IPPB is a specialized for of noninvasive ventilation(NIV) used for a relatively short treatment periods (approx. 15 minutes per treatment)

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IPPD is intendend to

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provide some machine-assisted deep breaths and assist in coughing. Not full ventilatory support. Periodic sessions of IPPB can be useful in the treatment of pulmonary conditions or exacerbations of lung disease

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Useful in what patients?

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clinically diagnosed with atelectasis unresponsive to other therapies such as IS, deep breathing and CPT.

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Optimal Breathing Pattern

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would be to reinflate collapsed alveoli/lungs, would be a slow, deep breath that are sustained or held at the end inspiration This maneuver will increase the distribution of inspired gas to areas of the lung with low compliance or atelectatic areas

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A baseline assessment

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General evaluation assessment Vital signs Assessment of patients appearance and sensorium Assessment of breathing pattern and breath sounds

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Always check what before use?

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The Equipment

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Questions to answer of IPPB Therapy

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1. Why the Dr. ordered the treatment 2. What the treatment does 3. how it will feel 4. What are the expected results

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The IPPB machine should

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be set so that a breath can be initiated with minimal patient effort *Sensitivity or trigger should be set at a level of -1 to -2 Cm H2o*

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"pressure cycled"

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This means that inspiration ends when a preset pressure is reached in the circuit Preset pressure is set by the therapist

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Typical Pressures

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-Typical pressure ranges (15 - 25 cmH2O), it may take 30-35 cmH2O to achieve your Vt goal -IPPB VT should be 10 to 15 ml/kg of body weight or at least 30% of the patients predicted Inspiratory capacity (IC ) *Pressures higher than 25 associated with "air swallowing" particularly with mouth seal or mask treatments Pressures less than 15 may be insufficient to increase the tidal volume (Vt)*

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Characteristics of Pressure Cycling

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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 deliver any specific volume to the patient Volume delivered is based upon; the patients ability to relax and let the machine deliver the 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 (PAP) Therapy

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PAP adjuncts use positive pressure to increase the PL gradient and enhance lung expansion

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There are 3 current approaches to PAP Therapy:

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PEP EPAP CPAP

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Used most often as part of Airway Clearance

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PEP EPAP

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CPAP

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maintains a positive airway pressure throughout both inspiration and exhalation *Maintains a high alveolar and airway pressures throughout the full breathing cycle*

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Beneficial Effects of CPAP

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1. Recruitment of collapsed alveoli via and increase in FRC 2. Decreased work of breathing secondary to increased compliance or elimination of intrinsic positive and expiratory pressure (PEEP) 3. improved distribution of ventilation through collateral channels 4. Increase in the efficiency of secretion removal

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CPAP should be used until

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the patient recovers, due to the increase in FRC that is lost after 10 minutes of the treatment being done.

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Contraindicate CPAP Therapy

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Patients who are hemodynamically unstable Patients suspected to have hypoventilation because it does not ensure ventilation Patients with nausea Facial trauma Untreated pneumothorax Elevated intracranial pressure (ICP)

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Hazards and Complications of CPAP Therapy

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Caused by either the increased pressure or the apparatus Barotrauma is a potential hazard, and is likely to occur in a patient with emphysema May cause gastric distension especially when values are greater than 15 cm H2O *May lead to vomiting or aspiration in a patient with an inadequate gag reflex*

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Plan for the therapeutic outcomes or improvements in

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Breath sounds Vital signs Radiograph findings Restoration of normal oxygenation

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Monitoring & Troubleshooting of CPAP

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Patients must be able to maintain adequate excertion of carbon dioxide for CPAP to be successful Patients must be monitored for adverse or untoward effects Must have monitors to evaluate pressure being given and alarms to indicate loss of pressure due to disconnection or mechanical failure You have to watch for system leaks and make sure there is a tight seal when using a mask *Irritation from the mask may occur with prolonged use*

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CPAP therapy needs:

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-planning -patient assessment -implementation -throughout follow up

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How to Select an Approach Lung Therapy

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Always use the safest, simplest, and most effective method for an individual patient Patients must meet criteria for therapy by having one or more indications

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EzPAP-

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EzPAP® is the easy option for the prevention and treatment of atelectasis and a medical need for lung expansion therapy. When incentive spirometry alone won't open patient's airways, expand your options with EzPAP®.

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EzPAP instructions

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It makes providing positive airway pressure positively easy. Simply connect to a flow meter (wall air or O2 for enhanced FiO2), adjust 5-15 L/min, and instruct the patient to breathe normally through the mouthpiece or mask. Just a few minutes of therapy, as needed - not for hours at a time.

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MetaNeb System

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Includes 3 therapies: -Lung Expansion -Airway Clearance -Aerosol delivery

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MetaNeb System Indications

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Mobilization of secretions Lung hyperinflation/lung expansion -To open airways -Treatment and prevention of pulmonary atelectasis Can provide supplemental oxygen

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MetaNeb used for patients with:

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COPD Neuromuscular disorders Cystic fibrosis Asthma Reversal of atelectasis

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MetaNeb Delivery options:

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In line ventilation Mouth piece Mask Tracheostomy

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MetaNeb Facts

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One circuit for this device that can give all 3 therapies Single patient use circuit Easily adjustable flow, pressure, and percussion rate Time effective treatments Can be used in adults and pediatrics

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CPEP

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Continuous Positive Expiatory Pressure, used to assist in holding open and expanding the airways

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CHFO

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Continuous High Frequency Oscillation, a for of chest physiotherapy that delivers an aerosol while oscillating the airways

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The MetaNeb therapy treatment consists of

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alternating between CPEP and CHFO modes while giving an aerosol treatment to minimize clinician time

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