Hyperinflation Therapy

Objectives - Identify IPPB therapeutic settings, perform intermittent positive pressure breathing, instruct a patient on incentive spirometry, and define sustained maximal inspiration.

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Intermittent Positive Pressure Breathing

Intermittent Positive Pressure Breathing (IPPB) delivers short-duration lung expansion therapy, also called hyperinflation therapy.

IPPB Indications

IPPB may be indicated for:

• Evidence of atelectasis on chest X-ray
• Ineffective, non-productive cough
• Neuromuscular disorders
• Kyphoscoliosis
• Muscle fatigue or weakness
• Exercise of respiratory muscles
• Acute severe bronchospasm in conjunction with adrenergic bronchodilators

The source notes that neuromuscular disorders and kyphoscoliosis involve decreased lung volumes.

Use as a Last Resort

IPPB has not been shown to provide benefit greater than other lung expansion techniques.

Because of that, IPPB should be used only as a last resort when other lung expansion therapies have failed.

Contraindications

IPPB is contraindicated with:

• Pneumothorax
• Intracranial pressure greater than 15 mmHg
• Nausea
• Radiographic evidence of a bleb
• Active hemoptysis
• Recent facial, oral, esophageal, or skull surgery
• Active, untreated tuberculosis

Disadvantages

• Mechanical effects are short-term, lasting approximately 15 minutes per treatment.
• IPPB can aerosolize medication but delivers 32% less medication than a simple handheld nebulizer.

Devices Listed in the Source

• Bird Mark 7
• PR-II
• Vortran

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Administering IPPB

Setup and Coaching

1. Introduce yourself to the patient and explain the procedure.
2. Position the patient comfortably, either sitting or semi-Fowler.
3. Determine the appropriate interface: mouthpiece or mask.
4. For a mask, apply it snugly over the nose and mouth.
5. For a mouthpiece, the patient must seal the lips around the mouthpiece.
6. Use nose clips to prevent leaks and improve the seal.
7. Instruct the patient to relax and offer no resistance to lung inflation.

Breathing Sequence

1. Inspiratory phase: instruct the patient to breathe in.
2. The inspiratory effort triggers the machine and delivers the pressurized breath.
3. Expiratory phase: when the lungs fill to maximum capacity, the patient exerts slight resistance.
4. The slight resistance cycles off flow and ends the pressurized breath.
5. The patient exhales passively and rests briefly before initiating the next breath.
6. Encourage the patient to cough as needed.

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IPPB Settings

Inspiratory Sensitivity

Inspiratory sensitivity is measured in negative cmH2O.

It determines the amount of effort required to trigger, or start, the machine breath. Sensitivity should be adjusted so the patient can trigger the machine without difficulty.

Inspiratory Pressure

Initial peak inspiratory pressure (PIP) is 15 to 20 cmH2O.

Inspiratory pressure:

• Is adjusted up or down for therapeutic effect and patient comfort
• Determines inspiratory volume and lung expansion
• Cycles off inspiration when the inspiratory pressure is met

Flow Rate

Initial flow rate is 30 L/min.

Flow rate:

• Determines the speed of gas flow during inhalation
• Is adjusted to provide an inspiratory time between 2 and 5 seconds
• Should be set according to patient comfort

Flow affects inspiratory time:

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Incentive Spirometry

Incentive spirometry (IS) facilitates sustained maximal inspiration (SMI) with visual indicators of inspiratory effort.

The visual feedback helps coach the patient on optimal performance and lets the patient monitor effort during therapy.

Sustained Maximal Inspiration

SMI is a slow, deep inspiration from functional residual capacity (FRC) to total lung capacity (TLC), followed by a breath hold of at least 5 seconds.

IS Indications

Incentive spirometry may be used to:

• Prevent atelectasis
• Minimize atelectasis
• Resolve atelectasis
• Support postoperative thoracic and abdominal surgical patients
• Support postoperative non-ambulatory patients who are predisposed to atelectasis

IS Contraindication

IS is contraindicated when the patient is uncooperative or unable to understand or perform the maneuver.

When the patient cannot perform IS, the source lists other therapy options:

• IPPB
• EzPAP
• IPV

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Incentive Spirometry Procedure

Pre-Procedure

1. Review the chest X-ray if available.
2. Provide the proper patient interface, such as mouth or trach.
3. Perform a physical assessment.
4. Assemble the device.
5. Set the target volume according to the device insert.
6. Position the patient for the procedure.

Positioning

Patient Instruction

1. Set the goal marker using the package insert.
2. Instruct the patient to exhale all air possible from the lungs.
3. Have the patient perform SMI to achieve the deepest breath possible.
4. Coach an inspiratory time of 5 to 15 seconds.
5. At end inspiration, have the patient hold the breath for 2 to 3 seconds.
6. Encourage forceful coughing between breaths to mobilize and expel secretions.

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High-Yield Review

IPPB

• IPPB is short-duration lung expansion therapy.
• It is used as a last resort when other lung expansion therapies have failed.
• Initial PIP is 15 to 20 cmH2O.
• Initial flow is 30 L/min.
• Flow is adjusted to an inspiratory time of 2 to 5 seconds.
• Sensitivity should allow the patient to trigger the machine without difficulty.

Incentive Spirometry

• IS facilitates SMI with visual feedback.
• SMI moves from FRC to TLC with a breath hold.
• IS is used to prevent, minimize, or resolve atelectasis.
• The patient should exhale fully, inhale slowly and deeply, hold briefly, and cough between breaths.