IPPB Part I Case studies: indications
Name:
Date: 2007
Case study # 1 Mr. Harbor
Mr. Harbor is a 65 year old WM with a history of CHF. His respiratory rate is 34 bpm and his HR is
99 bpm with a normal sinus rhythm. His BP is 140/88. His IBW is 65 kg
 On inspection: retractions with breathing; skin is diaphoretic with central cyanosis.
 On palpation: His pulse is strong; his skin is warm; poor chest excursion
 Percussion: dullness over the middle and lower lobes,
 On auscultation: crackles over the upper lobes and diminished breath sounds over the middle
and lower lobes.
 On X-ray: diffuse scattered infiltrates, cardiomegally and widespread atelectasis.
1.
How else would you assess this gentleman?
Pulse-ox, history of cardiac disease, depending on pulse ox maybe ABG, and measure
IC [with IS or with Wright Spirometer],
2.
Based on your assessment what do you want to do for him?
a. Start on supplementary 02 to decrease his WOB & decrease work of the heart.
With CHR with respiratory distress, a NRM is good.
b. If ABG, you could calculate his exact Fi02 needs.
c. If IC is less than 650 ml, start IPPB at 975 ml [which is 15 ml/kg]
3.
How would you assess the effectiveness and safety of the care you give him?
1. For safety, assess changes in VS, and BBS before and three minutes into and
after the TX.
2. For effectiveness, we can assess VS and BBS before and after
i. Pulse-ox for reversal of hypoxemia
ii. Wrights spirometer to recheck the pt’s IC,
iii. Check the PIP required to deliver the required VT.
iv. Check for the resolution of disease—check another X-ray to assess the
state of the atelectasis
4.
If your first recommendations fail and the IPPB is indicated, discuss the settings you would
pick for this patient.
 Rate: 6- 8 bpm
 Inspiratory time: 1 – 1.5 seconds
 VT: start at 12 ml/kg = 12 x 65 = 780 ml, can go up
 PIP: start low [10-15 cm] and measure VT till you get 780 ml
5.
If the patient’s compliance is 60 ml/cmH20 identify the PIP that would work to deliver the
VT you have selected?
VT/compliance = PIP we need
780 ml/60 = 12.6 ml/cmH20
6.
Are there any contra indications to IPPB for this patient?
No, except that he might need to be intubated or placed on BiPap
7.
What are the most likely [if any] hazards of IPPB with this patient?
Decreasing the venous return with this patient might actually help the heart in
congestive heart failure.
8.

If the IPPB is successful what do you expect:
to see on inspection immediately after the treatment?
Decreased WOB, improved VS, better colour. Less sweating and working so hard

To hear on auscultation immediately after the treatment?
BBS should have decreased crackles, increased air movement into the lower lobes

To see on the X-ray about 24-48 hours later?
Atelectasis resolving, better air movement into the lower lobes
Case study # 2 Miss. Barter
Miss Barter is a 35 year old BF with a history of asthma. Her respiratory rate is 34 bpm and her
HR is 100 bpm with a normal sinus rhythm. Her BP is 128/76. IBW is 58 kg. Her Sp02 is 93% on 4
lpm nasal cannula.
 On inspection: increased AP diameter, use of accessory muscles of inspiration and of exhalation;
her skin is diaphoretic with central cyanosis.
 On palpation: Her pulse is shows pulsus paradoxes & warm damp skin
 On percussion: hyper resonance over the upper lobes,
 On auscultation: diffuse inspiratory and expiratory wheezes, prolonged exhalation
 On X-ray: RML atelectasis with wide-spread signs of air trapping
1.
How would you assess this lady?
VS, pulse ox, because history + for asthma, PEFR for bronchospasm and possible IC for IPPB,
ABG to assess her C02, because if her C02 rises she might need to be ventilated
2.
Based on your assessment what do you want to do for her?
a.
Give supplementary 02 to get Sp02 above 95%
b.
Try SVN with albuterol 2.5 mg & atrovent with saline
c.
Start steroids iv or inhaled
d.
If IC was lower than 10 ml /cmH20 – 580 ml less we need to consider IPPB
with the beta II
3.
How would you assess the effectiveness and safety of the care you give her?
To assess the effectives of TX, we assess the VS & BBS and pulse ox
To assess the safety of the TX, we assess the VS, BBS and pulse ox
4.
If the doctor decides to order IPPB, are there any absolute contraindications for this
patient?
Wheezing can cause air-trapping; give IPPB with a Beta II
5.
If the doctor decides to order IPPB, identify any adverse hazards that this patient is at
particular risk for getting?
Air trapping and barotrauma such as pneumothorax
6.
Identify the VT you would pick for this patient.
12 ml/Kg = 12 x 58 = 696 ml VT
7.
do?
If the patient started breathing at a rate of 20 bpm on the IPPB, what would you have to
Get him to breath off the IPPB, then every 8-10 seconds take an IPPB breath. 6- 8
bpm on IPPB
8.
Explain your answer.
We want a SMI, so we need slow deep breaths with inspiratory holds. He doesn’t need
to breath so fast because we will decrease venous return to the heart and we can blow
off the C02 so he will get dizzy from hyperventilation
Case study # 3 Mr. Reed
Mr. Reed is a 19 year old WM with a history of a neuromuscular disorder. His respiratory rate is 33
bpm and his HR is 105 bpm with a normal sinus rhythm. His BP is 118/69. His IBW is 65 kg
 On inspection: paradoxical breathing, sweaty and central cyanosis.
 On palpation: His pulse is strong; with his skin is hot. You note poor chest excursion, particularly
over the lower part of his chest wall
 Percussion: you note dullness over the middle and lower lobes,
 On auscultation: you hear crackles over the upper lobes, rhonchi and diminished breath sounds
over the middle and lower lobes.
 On X-ray: low volume lung; diffuse scattered infiltrates, and widespread atelectasis in the LLL
and the RML.
1.
How would you assess this gentleman?
Pulse ox, history of recent and old history, ABG to r/o chronic hypercapnia
IC to r/o decreased ability to deep breathe and cough effectively. Sputum production
2.
Based on your assessment what do you want to do for him?
IPPB if the IC is less than 10 ml/kg--- less 650 ml –assess his cough with IPPB and if
he needs help suction
Low flow [1-2 lpm nasal cannula] 02 to get Sp02 above 90% keep at 92% is reasonable
2.5 mg Albuterol and normal saline with IPPB
3.
How would you assess the effectiveness and safety of the care you give him?
For effectiveness of IPPB: Monitor IC after IPPB, x-ray after IPPB, monitor
his ability to cough, & his sputum production,
For safety, VS [monitor BP if HR rises] BS, Sp02, monitor VT on IPPB
4.
5.
6.
7.
If the doctor orders IPPB, what setting do you pick?
 Rate: 6-8 bpm
 Inspiratory time: 1 – 1.5 seconds
 VT: 12 ml/kg = 12 x 65 = 780ml VT
If this patient’s lung compliance is 55 ml/cmH20, what PIP might you need to start with?
VT/compliance = pressure needed
780 ml/55 ml/cm = 14.18 cm PIP needed
Are there any contra indications to IPPB for this patient?
None that I can see
What are the most likely [if any] hazards of IPPB with this patient?
1. Persons with neuromuscular problems or quadriplegic are at increased risk of
hypotension, watch the IPPB rate so that his venous return is not affected.
2. There is a good chance that this patient might have chronic hypercapnia- give
his IPPB with compressed air so we don’t trigger 02 induced apnea
Case study # 4 Mrs. Rojas
Mrs. Rojas is a 45 year old LAF with a history of acute bacterial pneumonia. Her respiratory rate is
30 bpm and her HR is 115 bpm with a normal sinus rhythm. Her BP is 128/76. IBW 48 kg
 On inspection: you see someone who is breathing is rapid & shallow, with retractions ; central
cyanosis.
 On palpation: Her pulse is rapid and thready; her skin is hot and diaphoretic poor chest
excursion
 On percussion: you note hyper-resonance over the upper lobes, and dullness over the lower
lobes,
 On auscultation: you hear diffuse rhonchi, inspiratory and expiratory wheezes and crackles over
the RML. The lower lobes are distant
 On X-ray you see: atelectasis in the bilateral lower lobes and in the RML.
1.
How would you assess this lady?
Pulse ox , recent history, IC VS, PEFR
2.
Based on your assessment what do you want to do for her?
1. Give supplementary 02 to get Sp02 above 92%
2. Beta II drug- SVN if IC is above 10 ml/kg
3. If IC is below 10 then IPPB
4. Broad spectrum Antibiotic after culture sensitivity of sputum
3.
How would you assess the effectiveness and safety of the care you give her?
Assessment of effectiveness: VS, X-ray, sputum, pulse ox, IC and PEFR, BS
Assessment of safety: VS, If IPPB VS, return Vt. Pt’s subjective response to IPPB
4.
If the doctor orders IPPB, what setting do you pick?
 Rate: 6-8 bpm
 Inspiratory time: 1 – 1.5 seconds
 VT: 12 ml/kg = 12 x 48 = 576 ml VT
5.
If you started IPPB with PIP of 15 and you measured a VT of 300ml, what would you have to
do to give the proscribed VT?
Compliance is the ΔV/ ΔP = 300/15 = 20 ml/cmH20
We need 576 ml VT so VT/compliance = PIP
576/20 = 28.8 cmH20
Usually increasing the PIP to 24 and above can increase chances of swallowing air, and we
worry about barotrauma at such high pressures, so we would limit this to about 18 -20
6.
What effect would the IPPB breath have on the gas distribution into her lungs?
During IPPB, the gas flow will move toward the distal basal areas of the lung that have
atelectasis because of the pressure gradient between those alveoli and the airway
7.
Are there any contraindications for IPPB for this lady?
IPPB with saline is contraindicated, we must use a Beta II
This patient is at high risk of barotrauma, air trapping and pneumothorax.
I really would not want to suggest IPPB, she might need to be intubated for
respiratory failure rather than IPPB
8.
If you lack enough information to make a decision, what extra data might you need?
We need serial ABG to watch the progression of her PaCo2