Volume Expansion Therapy (VET)
RET 2275
Respiratory Care Theory 2
Volume Expansion Therapy (VET)

Volume Expansion Therapy

AKA


Lung expansion therapy
Hyperinflation therapy
A variety or respiratory care modalities
designed to prevent or correct atelectasis
by augmenting lung volumes

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Incentive Spirometry (IS)
Intermittent Positive Airway Pressure (IPPB)
Continuous Positive Airway Pressure (CPAP)
Positive Expiratory Pressure (PEP)
Volume Expansion Therapy (VET)

Atelectasis

Definition: alveolar collapse

Types:

Obstructive
 Caused by mucus plugging of airways

Passive
 Cause by constant tidal breathing of small volumes
 Common complication in postoperative patients
Volume Expansion Therapy (VET)

The Sigh Mechanism

Definition: the automatic, periodic inhalation of a large
tidal volume to prevent passive atelectasis

Normally, a person sighs about 6-10 times per hour

Passive atelectasis can occur if this mechanism is
impaired or lost
Volume Expansion Therapy (VET)

The Sigh Mechanism

Factors that can impair the sigh mechanism

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General anesthesia
Pain
Pain medication
Decreased level of consciousness
Thoracic or upper abdominal surgery
Impaired diaphragmatic movement
Volume Expansion Therapy (VET)

Sustained Maximal Inspiration (SMI)

A slow, deep inhalation form the FRC up to
(ideally) the total lung capacity, followed by a 5
– 10 second breath hold

Designed to mimic natural sighing

The negative alveolar & pleural pressures
reexpand collapsed alveoli and prevent the
collapse of ventilated alveoli
Volume Expansion Therapy (VET)

Indications


Presence of pulmonary atelectasis
Presence of condition predisposing to
atelectasis
Upper abdominal surgery
 Thoracic surgery
 Surgery in patient with COPD
Presence of a restrictive lung defect associated with
quadriplegia and/or dysfunctional diaphragm


Volume Expansion Therapy (VET)

Contraindications for VET

Inability of patient to be instructed to perform SMI
maneuver

Lack of patient cooperation

Inability of patient to deep breathe (i.e. VC <10 ml/kg)
Volume Expansion Therapy (VET)

Hazards & Complications of VET

Ineffective in absence of correct technique (may
require repeated instruction & coaching)

Hyperventilation

Exacerbation of bronchospasm
Volume Expansion Therapy (VET)

Hazards & Complications of VET

Hypoxemia (if O2 therapy is interrupted)

Barotrauma (in emphysematous lungs)

Fatigue

Pain in postoperative patients
Volume Expansion Therapy (VET)

Assessment of Need

Evidence of atelectasis based on physical exam & xray findings

Upper abdominal or thoracic surgery

Presence of predisposing conditions

Presence of neuromuscular disease affecting the
respiratory muscles
Volume Expansion Therapy (VET)

Findings Consistent with Atelectasis

Diminished breath sounds & fine crackles in affected
area

Fever

Tachypnea & tachycardia

Dull percussion note

Characteristic opacity on chest x-ray
Volume Expansion Therapy (VET)

Incentive Spirometry Equipment

Device is only a visual aid

Importance is placed on patient performing the correct
maneuver
Volume Expansion Therapy (VET)
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Incentive Spirometry (IS)
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Equipment

Volume IS
Volume Expansion Therapy (VET)

Incentive Spirometry (IS)

Equipment

Flow oriented

(flow x time = volume)
Volume Expansion Therapy (VET)

Incentive Spirometry (IS)
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Administering IS
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Physician order required
Instruct patient
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Importance of deep breathing
Demonstration is the most effective way to assist the
patient’s understanding and cooperation
Position patient

Sitting or semi-Fowler’s
Semi-Fowler’s Position
(Head elevated 30)
Volume Expansion Therapy

Incentive Spirometry (IS)
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Administering IS

RT should set initial goal (e.g. certain volume)


Instruct patient to inspire SLOWLY and deeply


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Should require some moderate effort
Maximizes distribution of ventilation
Ensure that the patient is using diaphragmatic breathing
Instruct patient to sustain maximal inspiratory
volume for 5 – 10 seconds followed by a normal
exhalation
Volume Expansion Therapy

Incentive Spirometry (IS)

Administering IS

Give the patient an opportunity to rest



Some patients need 30 seconds to one minute
Helps prevent hyperventilation, dizziness, numbness
around the mouth, respiratory alkalosis
IS regimen should aim to ensure a minimum of 5 10 SMI maneuvers each hour

Once technique is mastered, minimum supervision is
required
Volume Expansion Therapy (VET)

Assessment of Outcome
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Absence of or improvement in signs of atelectasis

Normal respiratory & heart rates

Afebrile

Absence of abnormal breath sounds
Volume Expansion Therapy (VET)
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Assessment of Outcome
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Normal chest x-ray
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Improved oxygenation (PaO2/SpO2)

Return of normal spirometric values

Improved respiratory muscle performance
Volume Expansion Therapy

Incentive Spirometry (IS)

Charting IS
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Pre-treatment vital signs
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Initial goal
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HR, RR, Breath sounds
Example: 800 ml x 10 SMI
Patient toleration
Post-treatment vital signs
Patient education

See examples of charting notes on next slide
Volume Expansion Therapy (VET)

Incentive Spirometry (IS) - Charting
Example of Chart Note:
1/31/06, 08:30
IS given to patient sitting in chair. HR = 80 - 72,
RR = 16 - 14, Breath sounds decreased at bases bilaterally, some
fine crackles noted at end inspiration. Obtained IS goal of 2.0 L x 7
SMI. Patient has a dry, non-productive cough. Breath sounds
unchanged after treatment. Patient tolerated treatment without
incident.
Example of Patient Education Note:
Instructed patient regarding the importance taking deep breaths after
surgery. Demonstrated IS technique for patient. Patient verbalized
understanding of therapy and gave a return demonstration with IS.
Sy Big, MDC Student
Respiratory Care
Volume Expansion Therapy (VET)

Important Points Regarding Use of IS

Verify that there is an indication for therapy

Effective patient teaching & coaching is essential


Demonstrate technique for patient
Teach splinted coughing

Place device within patient’s reach

Provide rest periods as necessary
CPAP

Definition

The application of a
positive airway pressure
to the spontaneously
breathing patient
throughout the
respiratory cycle at
pressures of 5 – 20 cm
H2O
CPAP

Physiological Principles

CPAP elevates and maintains high alveolar and
airway pressures throughout the full breathing cycle.
CPAP

Physiologic Principles - Equipment

The patient on CPAP breaths through a pressurized
circuit against a threshold resistor, with pressures
maintained between 5 – 20 cm H2O
CPAP

Physiologic Principles - Equipment
CPAP

Physiologic Principles

CPAP

Recruits collapsed alveoli via an increase in FRC
CPAP

Physiologic Principles

CPAP
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Recruits collapsed alveoli via an increase in FRC
Decreases work of breathing due to increased compliance
or abolition of auto-PEEP
Improves distribution of ventilation through collateral
channels (e.g., Kohn’s pores)
Increases the efficiency of secretion removal
CPAP

Indications

Postoperative atelectasis

Cardiogenic pulmonary edema
Refractory hypoxemia
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

PaO2 <60 mm Hg, SaO2 <90% on an FiO2 >0.40 – 0.50 in
the presence of adequate ventilatory status (PaCO2 <45
mm Hg, pH 7.35 – 7.45)
Obstructive sleep apnea
CPAP

Contraindications

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Hemodynamic instability
Hypoventilation
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CPAP does not ensure ventilation
Nausea
Facial trauma
Untreated pneumothorax
Elevated intracranial pressure
CPAP

Hazards and Complications

Increased work of breathing caused by the apparatus


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Patients with ventilatory insufficiency may
hypoventilate during application
Barotrauma
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Hypoventilation and hypercapnia
More likely in patients with emphysema and blebs
Gastric distention (CPAP pressures >15 cm H2O)

Vomiting and aspiration in patients with an inadequate gag
reflex
CPAP
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Monitoring and Troubleshooting


Patients must be able to maintain adequate excretion
of CO2 on their own
System pressure must be monitored


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Alarms need to indicate system disconnect or mechanical
failure
Masks may cause irritation and pain
Adequate flow to meet patient’s need


Flow initially set to 2 – 3 times the patients minute
ventilation
Flow is adequate when the system pressure drops no more
than 1 – 2 cm H2O during inspiration
CPAP
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Patient Interfaces
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Nasal Mask
CPAP

Patient Interfaces

Fitting the Nasal Mask
 Dorsum of nasal bridge
 Around the nasal alae
 Mid philtrum
 Use foam bridge

Prevents collapse of mask
onto nose
CPAP

Patient Interfaces

Fitting the Nasal Mask
 DO NOT over tighten

Tissue necrosis
CPAP – Tissue necrosis
CPAP

Patient Interfaces
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Full-Face Mask
CPAP
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Patient Interfaces

Fitting the Full-Face Mask
 Dorum of nasal bridge
 Surrounds nose/mouth
 Rests below lower lip
 DO NOT over tighten


Tissue necrosis
Foam bridge

Prevents collapse of mask
onto nose
CPAP

Nasal vs. Full-Face Mask

Nasal Masks
 More prone to air leaks (especially mouth
breathers)


Use chin strap
Full-Face Mask
 Increase dead space
 Risk of aspiration
 Claustrophobia
 Interferes with expectoration of secretions,
communication, eating
CPAP

Patient Interfaces

Total Face Mask
EZ-PAP



Lung expansion therapy
during inspiration and
PEP therapy during
exhalation
Used for the treatment or
prevention of atelectasis
and the mobilization of
secretions
Aerosol drug therapy
may be added to a PEP
session to improve the
efficacy of bronchodilator
EZ-PAP

EZ-PAP
EZ-PAP
EZ-PAP with SVN
IPPB

Definition

The application of inspiratory positive pressure
to a spontaneously breathing patient as an
intermittent or short-term therapeutic modality
IPPB

Definition

The delivery of a slow deep sustained
inspiration by a mechanical device providing
controlled positive pressure breath during
inspiration
IPPB

Indications (AARC)

The need to improve lung expansion


Treatment of atelectasis not responsive to other
therapies, (e.g., IS and CPT)
Inability to clear secretions adequately


Limited ventilation
Ineffective cough
IPPB

Indications (AARC)

Short-term nonivasive ventilatory support for
hypercapnic patients

Alternative to intubation and continuous
ventilatory support
IPPB

Indications (AARC)

The need to deliver aerosol medication


When MDI or nebulizer has been unsuccessful
Patients with ventilatory muscle weakness or
fatigue
IPPB

Contraindications (AARC)
Tension pneumothorax
________________________________________
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ICP > 15 mm Hg
Hemodynamic instability
Recent facial, oral or skull surgery
IPPB
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Contraindications (AARC)
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Tracheoesophageal fistula
Recent esophageal surgery
Active hemoptysis
Nausea
Air swallowing
IPPB
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Contraindications (AARC)
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Active, untreated TB
Radiographic evidence of bleb
Singulus (hiccups)
IPPB
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Hazards (AARC)
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Increase airway resistance (Raw)
Barotrauma, pneumothorax
Nosocomial infection
Hyperventilation (hypocapnia)
Hemoptysis
IPPB

Hazards (AARC)
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Hyperoxia when O2 is the gas source
Gastric distention
Secretion impaction (inadequate humidity)
Psychological dependence
Impedance of venous return
IPPB
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Hazards (AARC)
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Exacerbation of hypoxemia
Hypoventilation
Increased V/Q mismatch
Air trapping, auto peep, overdistended alveoli
IPPB
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Potential Outcomes

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Improved IC or VC
Increased FEV1 or peak flow
Enhanced cough or secretion clearance
Improved Chest radiograph
Improved breath sounds
IPPB

Potential Outcomes
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
Improved oxygenation
Favorable patient subjective response
IPPB

Baseline Assessment

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Vital signs
Patient’s appearance and sensorium
Breathing pattern
Breath sounds
IPPB

Implementation

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Infection control
Equipment preparation


Pressure check machine/circuit
Patient orientation




Why MD ordered therapy
What treatment does
How it feels
Expected results
IPPB

Implementation

Application



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Mouthpiece / nose clip (initially)
Mouthseal
Mask
Trach adaptor
IPPB

Implementation

Machine settings

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
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Sensitivity of 1 – 2 cm H2O
Initial pressure between 10 – 15 cm H20
Breathing pattern of 6 breaths/min
I:E ration of 1:3 to 1:4
Flow and pressure will need subsequent
adjustment to patient’s needs and goal
IPPB

Implementation

When treating atelectasis


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

Therapy should be volume-oriented
Tidal volumes (VT) must be measured
VT goals must be set
VT goal of 10 – 15 mL/kg of body weight
Pressure can be increased to reach VT goal if
tolerated by patient
IPPB

Implementation

When treating atelectasis

IPPB is only useful in the treatment of atelectasis
if the volumes delivered exceeds those volumes
achieved by the patient’s spontaneous efforts
IPPB

Discontinuation and Follow-Up
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Treatments typically last 15-20 minutes
Repeat patient assessment
Identify untoward effects
Evaluate progress
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