IPPB part I
case studies
Elizabeth Kelley Buzbee AAS, RRTNPS, RCP
► Case
study # 1
► Your patient is a 65 year old WF who just
had pelvic surgery. She is in traction. To
treat her effectively, what do you want to
assess at this point?
answer
► VS:
HR is 120 bpm, RR 28 bpm
► LOC: she is sleepy and complaining of pain
but answers appropriately
► Breath sounds: diminished basal breath
sounds and rhonchi and crackles in the
upper lobes
► Prior medical history: in good health prior to
this surgery
► Based
on the data you have collected what
else might you want to see?
answer
► Sp02
for s/s of respiratory distress:
Sp02 88%
► Inspection for labored breathing and
for chest wall movement: poor chest
wall movement, with substernal retractions
►
► What
do you think is wrong with this lady?
answer
► She
is suffering post-op atelectasis and she
is hypoxic on room air
► What
do you want to do for this patient
FIRST?
► ANSWER:
► Start
02 to get her Sp02 above 92%
► After
you start her on 2 lpm nasal cannula,
you see that the Sp02 is still 88%. What do
you suggest to the doctor?
► You
suggest that we raise the Fi02, you
might also ask for an ABG so we can
calculate exactly how high to raise the Fi02
►.
► This
is done and you get a Pa02 of 57 torr
on 2 lpm. Where do you want to raise the
Fi02, based on this new data?
answer
►
Based on Pa02: Fi02 Pa02
Fi02
, you
decide you need a Pa02 80 torr.
as
you want :
you need
57 torr : .28 as 80 torr : X
57X = .28 (80)
57X = .28 (80)
57
57
The Fi02 you need = .39
You suggest entrainment mask at 40%
► After
she is put on 40% Fi02 her Sp02 is
95% and her respiratory rate drops.
► What do you want to do next?
► ANSWER:
► Start
her on IS at 15 ml/kg IBW, assess her
breath sounds, VS and respiratory effort for
safety and efficacy of the SMI
► How
would you assess this patient after IS?
► assess
her breath sounds: BS are
unchanged after 3 IS TX
► VS: HR and respiratory rate continue to stay
high after IS
► respiratory effort for safety and efficacy of
the SMI: Still with poor chest movement
► She has a weak cough
► What
do you want to assess now in order to
treat this patient effectively?
answer
► Look
at the X-Ray: the atelectasis has
spread from the one seen on the first day
► What is her IC on the IS?: the IC she gets
on the IS is only 8 ml/kg IBW
► Based
on the information in the last slide,
what do you want to suggest to the doctor?
answer
► She
needs IPPB at Air/Mix to deliver a Vt of
at least 15 ml/Kg/ IBW
► The doctor orders 2.5 mg of Albuterol in 2.5
ml of normal saline
► How
would you assess the safety &
effectiveness of this therapy?
answer
►
Measure the exhaled Vt to make sure she is getting
at least 15 ml/Kg IBW and that she is not exceeding
45 ml/Kg IBW:
 she is getting 25 ml/kg IBW at a pressure of 18 cmH02
►
VS before, 3 minutes into and after IPPB.
 Her HR was 115, rose to 125 in 3 minutes and was 145 after the
IPPB. Her respiratory rate on the IPPB is 15 bpm
►
Breath sounds before and after IPPB:
 Breath sounds increased in basal posterior
►
Cough?
 Strong cough with copious, thick green sputum
► How
do you want to modify her TX at this
point?
Answer:
► Her
Vt is ok
► Her respiratory rate on the IPPB needs to be
6-8 bpm to give her heart time to refill
► To make sure that Albuterol is not causing
the HR increase, stop TX after 3 minutes
and see if the HR decreases back to
baseline
► To make the thick secretions thinner,
suggest Acetylcysteine
Case study # 2
► Your
patient is a 55 year old LAM who is 5’
8’’ tall. He has been admitted for biopsy of
the lung for possible lung CA [cancer]
► How do you want to assess this gentleman
Answer:
►
prior medical history:
 history of working with asbestos
 20 pack/year smoking history
 Chronic bronchitis for several years
►
Inspection for s/s respiratory distress
 Respiratory rate 18 bpm and with no use of accessory muscles
 HR 110 bpm
►
Breath sounds:
 Scattered rhonchi to all lobes and wheezes over the RML. A plural rub over the LLL.
► Sp02 :
 Sp02 is 93% on Room Air
►
Sputum production
 Scanty, thick, yellowish sputum
► What
do you suggest to treat him at this
point?
► He
doesn’t need 02 right now, but he needs
a beta II bronchodilator and possibly a
mucolytic by SVN.
► After his surgery, he may need IS so you
could start him on IS to train him prior to
surgery
► The
patient goes to surgery and gets a
biopsy from his Right Middle Lobar
bronchus.
► In recovery room, he is sleepy and you start
him on IS. He only gets 8 ml/kg IBW
► What do you want to assess right now?
Answer:
► Before
you decide to give him IPPB, you
need to look at his post-op X-Ray to rule out
the presence of a pneumothorax
 He has no pneumothorax
► You
want to check for blood in his sputum
 He coughs up a teaspoon of bloody sputum
during his IS
► What
do you want to do now?
Answer:
► IPPB
is contraindicated in Hemoptysis and
he has bloody sputum.
► We need continue with the SVN with beta II
drug, and use segmental breathing,
► but we might have to consider decreasing
the concentration of the Acetylcysteine from
20% to 10% [add normal saline] because
Acetylcysteine can make bleeding worse by
triggering violent coughing
Case study # 3
► Your
patient is a 45 year old WM who is
status post [s/p] multiple trauma from a
MVA [moving vehicular accident]
► How do you want to assess this patient?
Answer:
►
Check chart for history of current illness [extent of injuries]
 Broken ribs, chest tube placed to drain hemothorax.
►
VS:
 RR 25, HR 118 bpm
►
Inspection for s/s of respiratory distress
 Shallow breathing, no retractions, no flaring
►
Sp02:
 Sp02 91% on 40%
►
Percussion
 No hyper-resonance over the chest
►
BS:
 Diminished BS over the LLL [area of chest tube] diminished over
RLL. Rhonchi over RUL
► What
else might be assessed?
answer
► X-ray
shows:
 LLL effusion, presence of chest tube in the
lower portion of the chest
► Check
history:
 no prior cardiopulmonary history
 IBW 65 kg
► What
do you want to treat ?
answer
► Start
supplemental 02 to get the Sp02
above 92%
► Initiate coughing, deep breathing
► start IS at a minimal IC of 780-975
► If reassess BS and cough effort after IS to
see if patient might need mucolytics via SVN
► After
the first IS, the patient can only get
600 ml, but he is c/o pain on inspiration
► What do you do?
answer
► Get
with nurse regarding his pain
medication schedule
► Schedule IS to match his pain-free time
► Patient’s
pain medication is increased and
he is sleepy and co-operative.
► After
three more IS, you note that his IC is
still only 600 ml.
► What else do you need to assess?
answer
► His
cough effort:
 Weak and unproductive
► His
VS: HR 125 RR 29 bpm
► His BS:
 Diminished basal BS
 Rhonchi and crackles over the middle and upper
lobes
► His
X-ray
 The effusion has almost resolved
 Atelectasis in the LLL and the RLL
► What
do you want to do now?
answer
► Start
IPPB at 975 ml to treat atelectasis
 Follow-up X-ray and BS to assess
► Give
beta II drug with normal saline
 Follow-up BS and VS to effectiveness and safety