FUNDAMENTAL OF RT 1
Lung Expansion Therapy • Patients who have difficulty taking deep breaths
Causes and Types of Atelectasis
Gas absorption atelectasis
- can occur either when there is a complete
interruption of ventilation to a section of the lung
or when there is a significant shift in
ventilation/perfusion (VQ).
• Gas distal to the obstruction is absorbed by the passing
blood in the pulmonary capillaries, which causes partial
collapse of the nonventilated alveoli.
• When ventilation is compromised to a larger airway or
bronchus, lobar atelectasis can develop.
Compression atelectasis
- results when the forces within the chest wall and
lung— specifically, the pleural pressure— are
exceeded by the transmural pressure, which is
what distends and maintains the alveoli in an open
state.
• Compression atelectasis is primarily caused by persistent
use of small tidal volumes by the patient. This situation is
common when general anesthesia is given, with the use of
sedatives and bed rest, and when deep breathing is painful,
as when broken ribs are present or surgery has been
performed on the upper abdominal region.
• Weakening or impairment of the diaphragm can also
contribute to compression atelectasis. Compression
atelectasis results when the patient does not periodically
take a deep breath and expand the lungs fully.
• It is a common cause of atelectasis in hospitalized
patients.
• It may occur in combination with gas absorption
atelectasis in a patient with excessive airway secretions
who breathes with small tidal volumes for a prolonged
period.
Factors Associated With Causing Atelectasis
• Atelectasis can occur in any patient who cannot or
does not take deep breaths periodically and in
patients who are restricted to bed rest for any
reason.
without assistance include patients with
significant obesity, patients with neuromuscular
disorders or who are under heavy sedation, and
patients who have undergone upper abdominal or
thoracic surgery.
• Impairment of the function of pulmonary
surfactant can also have an impact on the
development of atelectasis.
Clinical Signs of Atelectasis
• Medical history
• Recent upper abdominal or thoracic surgery
• A history of chronic lung disease or cigarette
smoking
• Patient’s respiratory rate increases proportionally.
• Fine, late-inspiratory crackles may be heard over
the affected lung region. Bronchial-type breath
sounds may be present as the lung becomes more
consolidated with atelectasis.
• 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.
• The chest radiograph is often used to confirm
• The atelectatic region of the lung has increased
opacity.
• Direct signs of volume loss on the chest film
include displacement of the interlobar fissures,
crowding of the pulmonary vessels, and air
bronchograms.
• Indirect signs include elevation of the diaphragm;
shift of the trachea, heart, or mediastinum;
pulmonary opacification; narrowing of the space
between the ribs; and compensatory
hyperexpansion of the surrounding lung.
• All modes of lung expansion therapy increase lung
volume by increasing the transpulmonary pressure (PL)
gradient.
• PL gradient represents the difference between the
alveolar pressure (Palv) and the pleural pressure (Ppl): PL
= Palv – Ppl
 FUNDAMENTAL OF RT 1

Hazards and Complications of Incentive Spirometry

• Hyperventilation and respiratory alkalosis
• Discomfort secondary to inadequate pain control
• Pulmonary barotrauma
• Exacerbation of bronchospasm
• Fatigue
Equipment
• True volume-oriented devices measure and visually
indicate the volume achieved during an SMI.

Incentive Spirometry • The most popular true volume-oriented IS devices

employ a bellows that rises according to the inhaled
• The purpose is to guide the patient to take a sustained volume.
maximal inspiratory effort resulting in a decrease in Ppl
and maintain the patency of airways at risk for closure. • When the patient reaches a target inspiratory volume, a
controlled leak in the device allows the patient to sustain
• IS devices are designed to mimic natural sighing by the inspiratory effort for a short period (usually 5 to 10
encouraging patients to take slow, deep breaths. seconds).
• IS has been shown to be an efficient and effective
prophylaxis against postoperative atelectasis in high-risk
patients.
• The desired volume and number of repetitions to be
performed are initially set by the RT or other qualified
caregiver.
Indications
• Presence of pulmonary atelectasis
• Presence of conditions predisposing to atelectasis
• Upper abdominal surgery
• Thoracic surgery • Flow-oriented devices measure and visually indicate the
• Surgery in patients with COPD degree of inspiratory flow
• Presence of a restrictive lung defect associated
with quadriplegia or dysfunctional diaphragm • This flow can be equated with volume by assessing the
duration of inspiration or time (flow x time = volume).

Contraindications for Incentive Spirometry

• 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.
• Patients unable to deep breathe effectively (VC < 10
ml/kg or IC < 1/3 predicted)
 FUNDAMENTAL OF RT 1
Preliminary Planning
Implementation
• The RT should set an initial goal that is attainable
to the patient yet requires a moderate effort.
• Setting an initial goal that is too low for the patient
results in little incentive and an ineffective
maneuver, at least initially. The patient should be
instructed to inspire slowly and deeply to
maximize the distribution of ventilation.
• The RT should observe the patient perform the
initial inspiratory maneuvers and ensure the
patient uses correct technique. Demonstration is
probably the most effective way to assist patient
understanding and cooperation.
• The RT instructs the patient to sustain his or her
maximal inspiratory effort for 5 to 10 seconds.
Patients should be encouraged to try not to breathe
in too fast or slowly and to attempt a brief breath
hold.
• A normal exhalation should follow the breath
hold, and the patient should be given the
opportunity to rest as long as needed before the
next SMI maneuver.
• Healthy individuals average about 6 sighs per
hour, an IS regimen should probably aim to ensure
a minimum of 5 to 10 SMI maneuvers each hour.
Follow-Up
Noninvasive Ventilation
• NIV has been documented to have beneficial effects for
patients who may need periodic, short-term support or
patients who are experiencing exacerbations of pulmonary
disease.
• NIV offers some benefits over traditional, invasive
ventilation owing to lower infection risk and reduced need
for sedation because of the absence of an artificial airway.
• Variations of NIV, including IPPB and PEP therapy.
Intermittent Positive Airway Pressure Breathing
Physiologic Basis
• IPPB is a specialized form of NIV used for
relatively short treatment periods (approximately
15 minutes per treatment).
• The intent of IPPB is not to provide full ventilator
support as with some other forms of NIV but to
provide some machine-assisted deep breaths
assisting the patient to deep breathe and stimulate
cough.
• Positive pressure is transmitted from the alveoli to
the pleural space during the inspiratory phase of
an IPPB treatment, causing Ppl to increase during
inspiration. .
• Depending on the mechanical properties of the
lung, Ppl may exceed atmospheric pressure during
a portion of inspiration.
• As with spontaneous breathing, the recoil force of
the lung, stored as potential energy during the
 FUNDAMENTAL OF RT 1

positive pressure breath, causes a passive • Impaction of secretions (associated with

exhalation. inadequately humidified gas mixture)
• As gas flows from the alveoli out to the airway • Psychologic dependence
opening, Paly decreases to atmospheric level, • Impedance of venous return
while Ppl is restored to its normal subatmospheric • Exacerbation of hypoxemia
range. • Hypoventilation or hyperventilation
• Increased mismatch of ventilation and perfusion
• Air trapping, auto-PEEP, overdistention
Indications
• May be useful for patients with clinically
Administration
diagnosed atelectasis unresponsive to other
therapies, such as IS and chest physiotherapy. Preliminary Planning
• Short-term use of NIV in the form of IPPB may
be useful for patients who are at high risk for
atelectasis and unable to participate in more
patient-directed techniques such as IS or even
deep breathing.
• Should not be used as a single treatment modality
for a patient with gas absorption atelectasis
because of excessive airway secretions.
• IPPB itself should not be thought of as the first
line of therapy.
• Airways clearance with humidity therapy should
be considered in conjunction with IPPB for
optimizing results in patients with retained
secretions. Evaluating Alternatives
• A key component in early planning must be
Contraindications consideration of alternative therapies.

• Tension pneumothorax • Specifically, before starting IPPB, the RT and

prescribing phycisian must determine whether simpler and
• ICP > 15 mm Hg
• Hemodynamic instability less costly methods might be as effective in achieving the
desired outcomes.
• Active hemoptysis
• Tracheoesophageal fistula • If this is the case, further consideration of IPPB should
• Recent esophageal surgery be postponed until the patient's response to the simpler
• Active, untreated tuberculosis therapy is assessed.
• Radiographic evidence of blebs
• Recent facial, oral, or skull surgery
• Singultus (hiccups) Baseline Assessment
• Air swallowing The general assessment, common to all patients for whom
• Nausea IPPB is ordered, includes:
Hazards and Complications (1) Measurement of vital signs,
• Increased airway resistance and work of breathing (2) Observational assessment of the patient's
• Barotrauma, pneumothorax appearance and sensorium, and
• Nosocomial infection (3) Breathing pattern and chest auscultation.
• Hypocarbia
• Hemoptysis
• Gastric distention
 FUNDAMENTAL OF RT 1

Implementation Discontinuation and Follow-up

Equipment Preparation - the responsibility of the RT to Post Treatment Assessment
ensure that all components are in proper working order
• At the end of a treatment session, the patient assessment
before any use in patients.
is repeated.
Patient Orientation - explanation should be tailored to
• Treatment frequency should be determined by assessing
the patient’s level of understanding and address, at a
patient response to therapy. For acute care patients, orders
minimum, the following points:
should be re-evaluated based on patient response to
(1) Why the physician ordered the treatment, therapy at least every 72 hours or with any change of
(2) What the treatment does, patient status.
(3) How it will feel,
(4) What are the expected results. Recordkeeping
• A succinct but complete account of the treatment session,
Patient Positioning - for best results, the patient should
including the pre assessment and post assessment results,
be in a semi-Fowler position.
must be entered in the patient's medical record according
to the approved institutional protocol.
Initial Application
• Any untoward patient responses also must be reported
• An initial trial of nose clips may be needed until immediately to responsible personnel, including at least
the technique is understood and the treatment can the prescribing physician and attending nurse.
be performed without them.
• The mouthpiece must be inserted well past the
Monitoring and Troubleshooting
lips, and a tight seal must be encouraged to
prevent gas leakage from the site.
• A sensitivity or trigger level of -1 to -2 cm H2O is
adequate for most patients.
• System pressure is set low
• The goal is to establish a breathing pattern
consisting of about 6 breaths per minute,
• With an expiratory time of at least three to four
times longer than inspiration (inspiratory-to-
expiratory [I : E] ration of ≤1 : 3 to 1 : 4).
• After the treatment begins and the patient's basic
ventilatory pattern is established, the pressure and
flow should be individually adjusted and
monitored according to the goals of the therapy.
• There are various ways of determining these
volume goals. Most clinical centers strive to
achieve an IPPB tidal volume of 10 to 15 ml/kg of
body weight or at least 30% of the patient's Positive Airway Pressure Therapy
predicted IC. Physiologic Basis
• If the initial volumes fall short of this goal and the
patient can tolerate it, the pressure is gradually There are three current approaches to PAP therapy:
increased until the goal is achieved. 1. PEP,
• Pressures of 30 to 35 cm H2O may be needed to 2. EPAP,
achieve this end when lung compliance is 3. CPAP.
reduced.
• If high pressures are required, care needs to be • CPAP elevates and maintains high alveolar and airway
taken to minimize the risk of gastric insufflation. pressures throughout the full breathing cycle; this
 FUNDAMENTAL OF RT 1

increases PL gradient throughout both inspiration and
expiration.
• Typically, a patient on CPAP breathes through a
pressurized circuit against a threshold resistor, with
pressures maintained between 5 cm H20 and 20 cm H2O.
To maintain system pressure throughout the breathing
cycle, CPAP requires a source of pressurized gas.
The following factors involving PAP, EPAP and CPAP
therapy contribute to the beneficial effects:
(1) Recruitment of collapsed alveoli via an increase
in FRC,
(2) Decreased work of breathing secondary to
increased compliance or elimination of intrinsic
positive end expiratory pressure (PEEP)
(3) improved distribution of ventilation through
collateral channels (e.g., Kohn pores),
(4) Increase in the efficiency of secretion removal.
Indications
• Treatment of postoperative atelectasis, as with all
mechanical techniques, the duration of beneficial
effects appears limited.
• The corresponding increase in FRC may be lost
within 10 minutes after the end of the treatment.
• For this reason, it has been suggested that CPAP
should be used on a continuous basis until the
patient recovers.
• CPAP by mask also has been used to treat
cardiogenic pulmonary edema.
• CPAP does not augment spontaneous ventilation,
patients with an accompanying ventilatory
insufficiency may hypoventilate during
application.
• Barotrauma is a more likely to occur in a patient
with emphysema and blebs.
• Gastric distention may occur especially if CPAP
values greater than 15 cm H2O are needed.
• This condition may lead to vomiting and
aspiration in a patient with an inadequate gag
reflex.
Equipment
a. A breathing gas mixture from an 02 blender.
b. Flows continuously through a humidifier.
c. Into the inspiratory limb of a breathing circuit.
d. A reservoir bag provides reserve volume if the
patient's inspiratory flow exceeds that of the
system. The patient breathes in and out
through a simple valveless.
e. T-piece connector.
f. A pressure alarm system with manometer
monitors the CPAP at the patient's airway.
The alarm system can warn of either low
(usually caused by a disconnection) or high
system pressure.
g. The expiratory limb of the circuit is connected
to a threshold resistor, in this case,
h. A water column.

Contraindications
• Hemodynamically unstable.
• A patient who is suspected to have
hypoventilation.
• Other problems that may indicate CPAP is not an
appropriate therapy include nausea, facial trauma,
untreated pneumothorax, and elevated intracranial
pressure (ICP).

Hazards and Complications Administering Intermittent Continuous Positive Airway

• The increased work of breathing caused by the
apparatus can lead to hypoventilation and
hypercapnia.
Pressure
Planning - during planning, the need for PAP therapy
should be determined, and desired therapeutic outcomes
should be set. Specifically, an improvement in breath
 FUNDAMENTAL OF RT 1

sounds, improvement in vital signs (e.g., lower respiratory Selecting Approach

rate), resolution of abnormal radiograph findings, and
restoration of normal oxygenation all would indicate that
the therapy has achieved its goal.
Procedures - whether used on an interminttent or
continuous basis, CPAP is a complex and potentially
hazardous approach to patient management. As with all
therapies, the appropriate CPAP level for a patient must
be determined on an individual basis. Initial application
and monitoring require a broader range of knowledge and
skill than required for simpler modes of lung expansion
therapy.

Monitoring and Troubleshooting

• Hypoventilation - close monitoring, activated
alarms.
• Leaks - ensuring mask was tight seal.
• Gastric insufflation and aspiration - (via IPPB
mask) use nasogastric tube at higher pressure.
The RT must also ensure that the flow is adequate to meet
the patient's needs with the use of CPAP systems.