Understand the causes of atelectasis.

• Gas absorption atelectasis- occurs either when there is a complete interruption of ventilation to a section of the lung or when there is a significant shift in V/Q; gas distal to obstruction is absorbed by passing blood
• Lobar atelectasis- can occur when ventilation is compromised in a larger airway or bronchus
• Compression atelectasis-occurs when the transthoracic pressure exceeds the trans alveolar pressure

Identify which patients are at the greatest risk for developing atelectasis and needing lung expansion therapy.

• obesity
• neuromuscular disorders
• heavy sedation
• surgery near diaphragm
• bed ridden/ bed rest
• poor cough
• history of lung disease
• restrictive chest-wall abnormalities

Define the clinical findings seen in atelectasis.

• History of recent major surgery
• Tachypnea
• Fine, late-inspiratory crackles
• Bronchial or diminished breath sounds
• Tachycardia
• Increased density and signs of volume loss on chest radiograph
• History of chronic lung disease or cigarette smoking or both

Describe how lung expansion therapy is able to reverse atelectasis.

• Lung expansion therapy corrects atelectasis by increasing the P_AL gradient by either: 1) decreasing the surrounding P_pl or 2) increasing the P_alv
• This can be accomplished by deep spontaneous breaths or by the application of positive pressure
• P_AL= P_alv (alveolar pressure) - P_pl (pleural pressure)

Baseline Assessment

before beginning therapy, a baseline assessment should be conducted

this information helps to individualize the treatment & allows objective evaluation of the patient's subsequent response to therapy

• measuring vital signs
• assessing the patient's appearance & sensorium
• assessing the breathing pattern through chest auscultation
• patient's level of motivation & their ability to follow instructions

Early Mobilization of the Patient

Intensive Care Unit Patients

• evidence supports that it is better for the overall recovery of patients to get them out of the bed and provide early ambulation.
• Complications of prolonged bed rest include: cardiovascular, pulmonary, gastrointestinal, and skin integrity issues
• Pulmonary complications of immobility: development of atelectasis, pneumonia, and pulmonary emboli (PE)
• Mobilization includes: not only walking, but also sitting, standing, and getting out of the bed into a chair

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Incentive Spirometry-

• indications- presence of pulmonary atelectasis; presence of conditions predisposing to atelectasis: upper abdominal surgery, thoracic surgery, surgery in patients with COPD; presence of a restrictive lung defect associated with quadriplegia or dysfunctional diaphragm

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Incentive Spirometry Contraindications

Contraindications

• 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, patient is unable to deep breathe effectively (VC< 10 mL/kg or IC< 1/3 of predicted)

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Incentive Spirometry Hazards and Complications

Hazards & Complications

• hyperventilation & respiratory alkalosis, discomfort secondary to inadequate pain control, pulmonary barotrauma, exacerbation of bronchospasm, fatigue

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Intermittent Positive Pressure Breathing (IPPB) Indications

Indications

• no data to support the use of IPPB as a method of preventing or expanding atelectasis
• patient with atelectasis not responsive to other modalities such as IS
• patient at high risk for atelectasis who cannot perform IS

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Intermittent Positive Pressure Breathing (IPPB) Contraindications

Contraindications

• tension pneumothorax
• ICP > 15 mm Hg
• hemodynamic instability
• active hemoptysis
• tracheoesophageal fistula
• recent esophageal surgery
• radiographic evidence of blebs
• recent facial, oral, or skull surgery
• singulars (hiccups)
• nausea

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Intermittent Positive Pressure Breathing (IPPB) Hazards and Complications

Hazards and Complications

• hyperventilation and respiratory alkalosis
• discomfort secondary to inadequate pain control
• pulmonary barotrauma
• exacerbation of bronchospasm
• fatigue

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Continuous Positive Airway Pressure (CPAP) Indications

Indications

• evidence supports the use of CPAP therapy in the treating postoperative atelectasis, with all mechanical techniques, the duration of beneficial effects appears limited

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Continuous Positive Airway Pressure (CPAP) Contraindications

Contraindications

• tension pneumothorax / untreated pneumothorax
• ICP > 15 mm Hg
• hemodynamic instability
• active hemoptysis
• tracheoesophageal fistula
• recent esophageal surgery
• radiographic evidence of blebs
• recent facial, oral, or skull surgery
• singulars (hiccups)
• nausea
• hypoventilation

List the indications, hazards and complications associated with the various modes of lung expansion therapy.

Continuous Positive Airway Pressure (CPAP) Hazards and Complications

Hazards and Complications

• barotrauma, pneumothorax
• nosocomial infection
• hypercarbia
• hemoptysis
• pressure ulcers from mask
• gastric distension
• impaction of secretions (associated with inadequately humidified gas mixture)
• impedance of venous return
• hypoventilation
• increased V_D
• vomiting and aspiration

Describe the primary responsibilities of the respiratory therapist in planning, implementing, and evaluating lung expansion therapy.

RTs are responsible for implementing, monitoring and documenting results of lung expansion therapy.

• in-depth knowledge of both methods available
• the specific condition and needs of the patient being considered for therapy

atelectasis

collapse of the distal lung parenchyma

compression atelectasis

collapse of a part of the lung as a result of an
external force compressing the lung.

continuous positive airway pressure
(CPAP)

a method of ventilatory support
whereby the patient breathes spontaneously without mechanical assistance
against threshold resistance, with pressure above atmospheric maintained at
the airway throughout breathing.

deep breathing/directed cough

movements used to improve pulmonary
gas exchange or to maintain respiratory function, especially after prolonged
inactivity or general anesthesia

egophony

physical examination finding of increased resonance of voice sounds
when auscultating the chest (e.g., due to lung consolidation).

gas absorption atelectasis

collapse of airways due to hyperoxygenation
and nitrogen washout.

incentive spirometry (IS)

purpose of IS is to coach the patient to take a sustained maximal inspiratory (SMI) effort resulting in a decrease in P_AL & maintaining the potency of airways at risk of closure

the process of encouraging a bedridden patient to take
deep breaths to avoid atelectasis; most often done with the use of an incentive
spirometer that provides feedback to the patient when a predetermined lung
volume is reached during inspiration

intermittent positive airway pressure
breathing (IPPB)

the application of positive-
pressure breaths to a patient for a relatively short period (10 to 20 minutes).

lobar atelectasis

a collapsing of the airways and or alveoli limited to one
lung segment.

noninvasive ventilation (NIV)

mechanical ventilation performed without intubation
or tracheostomy, usually using a mask.

high-flow nasal cannula (HFNC)

a variation of the standard nasal cannula
that can deliver both FiO2 and relative humidity greater than 90% by using
heated, humidified O2 with flows up to 50 L/min. These systems have been
shown to successfully treat moderate hypoxemia through a combination of
a high FiO2, distending PAP, and meeting or exceeding the patient’s minute
ventilation.

positive expiratory pressure (PEP)

an airway clearance technique in which
the patient exhales against a fixed-orifice flow resistor to help move secretions
into the larger airways for expectoration via coughing or swallowing.