Lung Expansion Therapy- Cairo 7 – Flashcards
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Gas distal to the obstruction is absorbed by the passing blood in the pulmonary capillaries, which causes partial collapse of the nonventilated alveoli Can occur either when there is a complete interuption of ventilation to a section of lung or when there is a significant shift in ventilation/perfusion (V/Q)
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Gas absorption Atelectasis
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Process of encouraging a bedridden patient to take deep breaths to avoid atelectasis; most often done with the use of an incentive spirometer that provides feedback to the patient when a predetermined lung volume is reached during an inspiratory breath
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Incentive Spirometry (IS)
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Application of positive pressure breaths to a patient for a relatively short period 10 - 20 minutes
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Intermittent positive Airway Pressure (IPPB)
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When ventilation is compromised to a larger airway or bronchus
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Lobar Atelectasis
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Mechanical ventilation performed without intubation or tracheostomy, usually with mask ventilation
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Noninvasive Ventilation (NIV)
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Airway clearance technique in which the patient exhales against a fixed orifice flow resistor to help move secretions into the larger airways for expectoration via coughing or swallowing
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Positive Expiratory Pressure (PEP)
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.Deep breathing/directed cough .Incentive Spirometry (IS) .Continuous positive airway pressure (CPAP) .Positive Expiratory Pressure (PEP) .Intermittent positive airway pressure breathing (IPPB)
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What are the most common modalities of lung expansion therapy
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To guide the patient into improving pulmonary function by maximizing alveolar recruitment and optimizing airway clearance.
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What is the common purpose of these modalities
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Functional Residual Capacity (FRC) In other words used to simulate a deep breath or sigh
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These therapies are all designed to increase
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Atelectasis can occur in any patient who cannot of does not take deep breaths periodically and in patients who are restricted to bed rest for any reason
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When can Atelectasis occur
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.Patients with significant obesity .Patients with neuromuscular disorders .Patients who are under heavy sedation .Patients who have undergone upper abdominal or thoracic surgery
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What type of patients have difficulty taking deep breaths without assistance
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.Patients medical history often provides the first clue in identifying atelectasis .Recent upper abdominal or thoracic surgery .History of chronic lung disease .History of smoking
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What are the clinical signs of atelectasis
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.Respiratory Rate increases . Fine, late-inspiratory crackles may be heard over the affected lung region .Bronchial-type breath sounds may be present as the lung becomes more consolidates .Diminished breath sounds are common when excessive secretions block the airways and prevent transmission of breath sounds. .Tachycardia may be present if atelectasis leads to significant hypoxemia
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What are the physical signs of atelectasis
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These crackles are produced by the sudden opening of distal airways with deep breathing
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What produces the Fine, late-inspiratory crackles heard with atelectasis
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There is a DIRECT relationship between the spontaneous respiratory rate and the degree of atelectasis present. Typically, as atelectasis progresses, respiratory rate increase proportionally
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Is there a direct or inverse relationship between respiratory rate and the degree of atelectasis
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The chest radiograph. The atelectatic region of the lung has increased opacity
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What is used often used to confirm the presence of atelectasis
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Volume loss
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Evidence of _______________ is present in patients with significant atelectasis
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.Displacement of the interlobar fissures .Crowding of the pulmonary vessel .Air bronchograms
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What are direct signs of volume loss on the chest film
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.Elevation of the diaphragm .Shift of the trachea, heart or mediastinum .Pulmonary opacification .Narrowing of the space between the ribs .Compensatory hyper expansion of the surrounding lung
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What are indirect signs of volume loss on the chest film
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The trans pulmonary pressure gradient
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All modes of lung expansion increase lung volume by increasing what
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Compression Atelectasis: Collapse of a part of the lung as a result of an external force compressing the lung Primarily caused by persistent use of small tidal volumes Gas absorption Atelectasis: Gas distal to the obstruction is absorbed by the passing blood in the pulmonary capillaries, which causes partial collapse of the nonventilated alveoli Can occur either when there is a complete interuption of ventilation to a section of lung or when there is a significant shift in ventilation/perfusion (V/Q)
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Compression Atelectasis VS. Gas absorption Atelectasis
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Compression Atelectasis
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What form of Atelectasis is caused by not taking normal tidal volumes
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Gas absorption atelectasis
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What form of Atelectasis is caused by not excess mucus plugs
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.Patients that are bed ridden .Patients that have COPD .Patients that have had upper abdominal surgery or thoracic surgery .Patients that have difficulty taking deep breaths .Impairment of the function of pulmonary surfactant
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What types of patients are at risk of developing atelectasis
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.Increased respiratory rate .Decrease tidal volumes .Changes in x ray .Patients medical history .Fine, late inspiratory crackles .Tachycardia may be present if atelectasis leads to significant hypoxemia
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What are the clinical signs of atelectasis
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Increases trans pulmonary pressure
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What does lung expansion therapy do to the trans pulmonary pressure gradient
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.If they can follow instructions .Most natural .Works off of negative pressure
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When is the Incentive Spirometer a good choice
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Decrease surrounding pleural pressure, which causes an increase in alveolar pressure
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How can the trans pulmonary pressure be increased
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.PEP (Positive end expiratory pressure) .IPPB .EPAP
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What are the lung expansion methods that are used to increase alveolar pressure
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Incentive Spirometry
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What lung expansion therapy should be used on a patient with no history of lung disease that is post op to prevent atelectasis
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.Patient cannot be instructed or supervised to ensure appropriate use of device .Patient cooperation is absent, or patient is unable to understand or demonstrate proper use of device .Patient is unable to beep breath effectively
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What are the contraindications for the I.S.
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.Presence of pulmonary atelectasis .Presence of conditions predisposing to atelectasis such as upper abdominal surgery, thoracic surgery, surgery in patients with COPD .Presence of a restrictive lung defect associated with quadriplegia or dysfunctional diaphragm
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What are the indications for the I.S.
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.Hyperventilation and respiratory alkalosis .Discomfort secondary to inadequate pain control .Pulmonary barotrauma .Exacerbation of bronchospasm .Fatigue .Ineffective unless closely supervised or performed as ordered .Inappropriate as sole treatment for major lung collapse or consolidation
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What are the hazards or complications for the I.S.
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.Flow oriented .Volume oriented
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What are the two types of I.S. devices
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Measure and visually indicate the volume achieved during an S.M.I (sustained maximal inspiration)
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Volume oriented I.S. device
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Measure and visually indicate the degree of inspiratory flow
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Flow oriented I.S. device
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.Improved aeration .Absence of or improvement in signs of atelectasis .Decreased respiratory rate .Normal pulse rate .Resolution of abnormal breath sounds .Normal or improved chest radiograph .Improved PaO₂ and decreased PaCO₂ .Increased SpO₂ .Increased VC and peak expiratory flows .Improved inspiratory muscle performance and cough .Increased FVC
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What are the signs and symptoms of patients that are improving from using the I.S.
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.Improved VC .Increased FEV₁ or peak flow .Enhanced cough and secretion clearance .Improved chest radiograph .Improved breath sounds .Improved oxygenation .Favorable patient subjective response
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What are the signs and symptoms of patients that are improving from using I.P.P.B
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A specialized form of NIV used for relatively short treatment periods (approx. 15 minutes per treatment). The intent of IPPB is not to provide full ventilatory support as with some other forms of NIV but to provide some machine assisted deep breaths assisting the patient to deep breathe and stimulate a cough. Uses positive pressure and is not considered to be patient friendly
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What is an I.P.P.B
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Passive
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Is exhalation considered to be active or passive
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.Patients that have no responded to other therapies (I.S.) .Those who cannot cooperate using other therapies
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What types of patients are considered to be good candidates for IPPB therapy
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Yes, usually caused by the RT
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Can IPPB cause overinflation of the lungs
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Yes
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Should bronchial hygiene be used in conjunction with IPPB therapy
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Slow deep breaths that are sustained or held at end inspiration
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What type of breathing pattern should be encouraged while using the IPPB
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Respiratory Alkalosis
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What is the most common complication associated with the use of IPPB
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.Need to improve lung expansion .Presence of clinically significant pulmonary atelectasis when other forms of therapy (IS) have been unsuccessful or the patient cannot cooperate .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 .Need for short term NIV support for hypercapnic patients .Need to deliver aerosol medication
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What are the indications of IPPB therapy
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.Tension pneumothorax (#1 contraindication) . ICP > 15 mm Hg .Hemodynamic instability .Active hemoptysis .Thracheoesophageal fistula .Recent esophageal surgery .Active, untreated TB .Radiographic evidence of blebs .Recent facial, oral, or skull surgery .Singultus .Air swallowing .Nausea
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What are the contraindications of IPPB therapy
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.Increased Airway resistance .Barotrauma .Nosocomial infection .Hypocarbia .Hemoptysis .Gastric distension .Impaction of secretions (associated with inadequately humidified gas mixture) .Psychologic dependence .Impedance of venous return .Exacerbation of hypoxemia .Hypoventilation or hyperventilation .Increased mismatch of ventilation and perfusion .Air trapping, auto PEEP, over distention
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What are the hazards of IPPB therapy
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Tension pneumothorax
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What is an absolute contraindication of IPPB therapy
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Respiratory Alkalosis, increased pH decreased CO₂, which is caused by hyperventilation
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What is the most common complication of IPPB therapy
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20 mm Hg
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What is the minimum pressure need to open the esophagus
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False: Gastric distension restricts movement of the diaphragm and causes an increase risk of aspiration
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True/False Gastric distension is considered harmless
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Plug the end that goes to the mouthpiece. If machine cycles off then no leaks. If machine stays on then a leak is present
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How to you check the IPPB circuit for leaks
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.Switch to a face mask .Use a nose plug
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What should you do if their are leaks around the mouthpiece while using an IPPB
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.Vital Signs .Breathing pattern .Sensorium .Patients appearance
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What should the RT monitor while the patient is using an IPPP machine
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1 - 2 cm
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How many cm do you increase the pressure by
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Check the tubing for a leak or a kink
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What should you check if the IPPB machine cycles off prematurely
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-1 to -2 mc H₂O
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What sensitivity level or trigger level is adequate for most patients
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6, with an expiratory time of at least 3 to 4 times longer than inspiration ( I:E ratio of 1:3 or 1:4)
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The goal is to establish a breathing pattern consisting of how many breaths per minute
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10 to 15 ml/kg of body weight or at least 30% of the patients predicted IC
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Most clinical centers strive to achieve an IPPB tidal volume of what
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Exceed the volumes achieved by the patients spontaneous efforts
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IPPB is useful in the treatment of atelectasis only if the volumes delivered _________
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At connections points such as the nebulizer of exhalation valve
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Where do IPPB machine leaks most commonly occur
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.PEP .EPAP .CPAP
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What are the 3 current approaches to PAP therapy
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.Post op atelectasis .Cardiogenic pulmonary edema
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What are the indications for use of the CPAP
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.Patient that is hemodynamically unstable .Patient who is suspected to have hypoventilation .Nausea .Facial trauma .Untreated pneumothorax .Elevated ICP
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What are the contraindication for use of the CPAP
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.Gastric distension .Barotrauma .RT didnt turn machine on .Increased WOB which can lead to hypoventilation or hyperventilation
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What are the hazards or complications associated with the use of CPAP
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.You will hear it .Decreased exhaled volume .Low pressure alarm
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How do you determine if their is a system leak with the CPAP
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.Recruitment of collapsed alveoli via an increase in FRC .Decreased work of breathing secondary to increase compliance or elimination of intrinsic positive end expiratory pressure (PEEP) .Improved distribution of ventilation through collateral channels (pores of Kohn) .Increased in the efficiency of secretion removal
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What are the factors involving PAP, EPAP and CPAP therapy contribute to the beneficial effects
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