Lung expansion therapy is a critical component in both preoperative preparation and postoperative recovery for patients undergoing surgical procedures, particularly those involving the thoracic and abdominal regions.
The therapy aims to prevent or reverse atelectasis, a condition characterized by the collapse or incomplete expansion of the alveoli (i.e., tiny air sacs) in the lungs.
Understanding the mechanisms, benefits, and best practices in lung expansion therapy is essential for healthcare providers seeking to minimize respiratory complications and improve patient outcomes.
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Atelectasis is a condition characterized by the partial or complete collapse of a lung or a section (lobe) of a lung. It occurs when the alveoli within the lung become deflated or filled with alveolar fluid.
Atelectasis can compromise oxygenation and may lead to serious complications if not addressed. It is often caused by a blockage of the air passages or by pressure on the outside of the lung.
Atelectasis is commonly seen after surgery or in patients who are bedridden and can also occur as a complication of other respiratory conditions.
Atelectasis can occur due to a variety of causes, which can be broadly categorized into obstructive and non-obstructive types:
Note: Understanding the underlying cause is crucial for the effective treatment of atelectasis.
The symptoms of atelectasis can vary in severity depending on the extent of lung involvement, the underlying cause, and the individual’s overall health.
Some common symptoms may include:
In some cases, especially if the atelectasis is small or develops slowly, symptoms may be minimal or even absent.
Due to the nonspecific nature of these symptoms, diagnostic tests like X-rays or CT scans are usually required for a definitive diagnosis.
Lung expansion therapy refers to various techniques aimed at preventing or treating atelectasis, a condition where lung tissues collapse or fail to inflate fully. These techniques help improve lung function by promoting the expansion of alveoli, thereby enhancing gas exchange and reducing respiratory complications.
Lung expansion therapy employs a variety of techniques to improve lung function, optimize alveolar inflation, and enhance gas exchange.
Here are some common types:
Note: Selecting the appropriate type of lung expansion therapy depends on the underlying condition, patient capabilities, and clinical judgment.
Early patient mobilization involves encouraging patients to engage in physical activities such as sitting, standing, or walking as soon as it is medically feasible.
This approach helps to prevent the collapse of alveoli by promoting lung expansion through increased respiratory effort and movement.
It’s particularly beneficial in the postoperative setting or for patients who are bedridden for extended periods.
Deep breathing exercises require the patient to take slow, deep breaths to fully inflate the lungs, while directed coughing involves a specific technique to help clear mucus and secretions.
This combination assists in optimizing lung volumes and maintaining open airways, thereby preventing or treating atelectasis.
Often, these exercises are guided by respiratory therapists and can be done with or without the aid of devices.
Incentive spirometry is a respiratory therapy technique that employs a hand-held device to facilitate sustained maximum inspiration (SMI).
Under the guidance of a respiratory therapist who sets an initial target volume, patients aim to reach predetermined levels of air intake.
The technique aids in improving lung function and preventing atelectasis by mimicking natural sighing, stimulating deep breathing, expanding the lungs, increasing alveolar ventilation, and enhancing the performance of inspiratory muscles.
The potential benefits of using incentive spirometry include decreased atelectasis, improved breath sounds, enhanced chest x-ray results, elevated levels of oxygen saturation (SpO2), increased vital capacity, a stronger cough, and improved respiratory muscle performance.
Continuous positive airway pressure (CPAP) is a respiratory therapy technique that uses a machine to deliver air at a pressure slightly higher than atmospheric through a mask covering the nose and mouth.
Although commonly employed to treat sleep apnea, CPAP is also effective in managing atelectasis. It accomplishes this by keeping the airways open, enhancing gas exchange, and providing positive end-expiratory pressure.
Additional potential benefits of CPAP therapy include increased levels of oxygenation, improved vital capacity, a stronger cough, and enhanced patient comfort.
Positive airway pressure (PAP) is a respiratory therapy technique that employs devices to deliver positive pressure to the airways, facilitating improved lung expansion.
While PAP includes various modalities like PEP (Positive Expiratory Pressure), flutter, and CPAP, in the context of treating and preventing atelectasis, the focus is on lung expansion rather than airway clearance.
PAP therapy is effective in increasing the patient’s functional residual capacity (FRC), which leads to the re-opening of collapsed alveoli.
This results in increased lung compliance, reduced work of breathing, improved collateral ventilation, and enhanced secretion removal.
Intermittent positive pressure breathing (IPPB) is a form of noninvasive ventilation that administers positive pressure during the inspiratory phase and returns to atmospheric pressure during expiration.
While the machine has the capability for full ventilatory support, its primary aim is not to replace natural breathing but to enhance it.
Specifically, IPPB is designed to help patients take deeper breaths, stimulate an effective cough, and prevent or decrease atelectasis. It achieves these goals by improving gas exchange, increasing lung compliance, and reducing the work of breathing.
Additional potential benefits of IPPB therapy include improved breath sounds, elevated levels of oxygenation, increased vital capacity, improved chest x-ray results, and a more robust cough.
A high-flow nasal cannula is a form of noninvasive ventilation that delivers a high flow of warm, humidified oxygen via a nasal cannula equipped with larger prongs.
This setup allows for higher flow rates and offers a comfortable experience for the patient. HFNC is particularly beneficial for patients with atelectasis for several reasons.
First, its enhanced flow capability helps to wash out CO2 from anatomic dead space. Second, it provides a more stable fraction of inspired oxygen (FiO2).
Lastly, the device delivers a modest amount of positive pressure due to higher inspiratory flows, aiding in the recruitment of collapsed alveoli. These features make HFNC effective in both treating and preventing atelectasis.
Note: These lung expansion therapies offer a range of options for healthcare providers to tailor respiratory care based on individual patient needs. Utilizing them appropriately can significantly improve patient outcomes by enhancing lung function and mitigating complications.
1. What is lung expansion therapy used for?
It is used to prevent or correct atelectasis and respiratory complications, often in postoperative patients.
2. What is gas absorption atelectasis?
Gas absorption atelectasis occurs when a mucus plug blocks ventilation to selected regions of the lung.
3. What is compression atelectasis?
A type of atelectasis caused by persistent breathing with small tidal volumes is common in certain types of restrictive chest wall disorders.
4. What factors can cause atelectasis?
Obesity, neuromuscular disorders, heavy sedation, surgery near the diaphragm, bed rest, poor cough, history of lung disease, and restrictive chest wall abnormalities.
5. What does atelectasis cause?
Decreased FRC, V/Q mismatch, arterial hypoxemia, decreased surfactant production, and an ineffective cough, which leads to retained secretions and possible pneumonia.
6. What are the clinical signs of atelectasis?
History of recent major surgery, tachypnea, fine late inspiratory crackles, bronchial or diminished breath sounds, tachycardia, and signs of volume loss on a chest radiograph
7. How does lung expansion therapy work?
It works by increasing the transpulmonary pressure gradient, which is the difference between alveolar and pleural pressure. The greater the transpulmonary pressure gradient, the more alveolar expansion will occur.
8. How can you increase the transpulmonary pressure gradient?
It can be increased by decreasing the surrounding pleural pressure or by increasing the alveolar pressure.
9. What therapy decreases pleural pressure?
Incentive spirometry
10. What therapy increases alveolar pressure?
IPPB and positive pressure therapies
11. What is another name for incentive spirometry?
Sustained maximal inspiration (SMI)
12. How does incentive spirometry work?
It mimics natural sighing by encouraging patients to take slow, deep breaths.
13. What are the indications for incentive spirometry?
The presence of pulmonary atelectasis; the presence of conditions that could cause atelectasis, like upper abdominal surgery, thoracic surgery, and surgery in patients with COPD; the presence of a restrictive lung defect associated with quadriplegia or a dysfunctional diaphragm.
14. What are the contraindications for incentive spirometry?
Unconscious patients or those unable to cooperate, inability to comprehend instructions, and patients unable to generate adequate inspiratory flow.
15. What are the hazards and complications of incentive spirometry?
Hyperventilation, discomfort, fatigue or overexertion, pulmonary barotrauma, and hypoxemia
16. How do you teach incentive spirometry?
Demonstrate, then observe the patient
17. When is the best time to teach incentive spirometry?
Prior to surgery
18. What must be performed before and after incentive spirometry?
Auscultation
19. What are the outcomes of incentive spirometry therapy?
Improvement of atelectasis, decreased respiratory rate, normal pulse rate, resolution of abnormal breath sounds, improved chest radiograph, improved PaO2, decreased PaCO2, increased SpO2, increased VC and peak expiratory flow, restoration of preoperative FRC or VC, improved inspiratory muscle performance and cough, attainment of preoperative flow and volume levels, and increased FVC.
20. What instructions are given for incentive spirometry?
Exhale normally, take slow deep inspirations, perform an inspiratory pause/breath-hold, take slow and passive exhalations, rest between breaths, and perform ten breaths every hour while awake.
21. What has to be documented during incentive spirometry?
Date and time given, type of treatment, goals reached and number of times, breath sounds before and after, cough and nature of secretions, and any adverse reactions.
22. What is intermittent positive pressure breathing?
A noninvasive technique that uses positive airway pressure to provide machine-assisted deep breaths and stimulates coughing.
23. How does IPPB work?
Positive pressure is applied to the airway and is transmitted to the alveoli and pleural space during inspiration. Gas flows into the lungs due to the pressure differences, and exhalation is passive.
24. What are the indications for IPPB therapy?
It is indicated in patients with atelectasis who aren’t responsive to other therapies and in patients who are at a high risk for atelectasis but can’t perform incentive spirometry.
25. What are the contraindications for IPPB?
Tension pneumothorax, ICP greater than 15 mmHg, hemodynamic instability, active hemoptysis, tracheoesophageal fistula, recent esophageal surgery, active untreated tuberculosis, radiographic evidence of blebs, recent facial oral or skull surgery, hiccups, air swallowing, and nausea.
26. What are the hazards and complications of IPPB?
Increased airway resistance, pulmonary barotrauma, nosocomial infections, respiratory alkalosis, hyperoxia, impaired venous return, gastric distension, air trapping, auto-PEEP, overdistention, and psychological dependence.
27. What baseline assessment should be performed before IPPB?
Medical history, vital signs, sensorium and appearance, breathing pattern, and auscultation.
28. What are the outcomes of IPPB?
Improved VC, increased FEV, enhanced cough and secretion clearance, improved chest radiograph, improved breath sounds, and improved oxygenation.
29. What are the alternative therapeutic methods to IPPB?
EzPAP, incentive spirometry, or pursed-lip breathing
30. What has to be documented when administering IPPB?
Pre-assessment, post-assessment, adverse effects, medications used, settings used, volume achieved, and length of the treatment.
31. What is the “triple S” rule for IPPB?
If a patient has a severe adverse reaction, you should stop the treatment, stay with the patient, and stabilize the patient.
32. What do PEP, EPAP, and CPAP stand for?
Positive expiratory pressure, expiratory positive airway pressure, and continuous positive airway pressure.
33. What is CPAP therapy?
A type of therapy where patients breathe through a pressurized circuit against a threshold resistor at pressures between 5 and 20 cmH2o. The CPAP machine maintains positive pressure during inspiration and expiration.
34. What are the indications for CPAP?
To recruit collapsed alveoli, decrease work of breathing, improve the distribution of ventilation, enhance secretion removal, treat cardiogenic pulmonary edema, and improve oxygenation.
35. What are the contraindications for CPAP?
Hemodynamic instability and hypoventilation
36. What are the hazards and complications of CPAP?
Barotrauma, hypoventilation, gastric distention, vomiting, and aspiration
37. What is the most common problem with CPAP?
System leaks
38. What should be monitored during CPAP?
Monitor for hypoventilation and an elevated PaCO2
39. How do you choose an approach for CPAP?
Choose the one that is safest, simplest, and most effective, and evaluate the patient’s level of cooperation, amount of pulmonary secretions, and spontaneous vital capacity.
40. What type of patients are at risk for postoperative atelectasis?
Patients with a history of lung disease that causes increased mucus production, patients with chronic bronchitis, patients who smoke cigarettes, and patients with a history of inadequate nutritional intake.
41. What is the cause of postoperative atelectasis?
An ineffective cough
42. What type of lung expansion therapy is physiologically most common?
Incentive spirometry
43. What is monitored during incentive spirometry?
Patient performance, frequency of sessions, number of breaths per session, inspiratory volume or flow goals, effort and motivation, compliance with technique, a device within reach and encouragement for the patient to do it independently, new and increasing inspiratory volumes each day, and vital signs.
44. What are the symptoms of hyperventilation during incentive spirometry?
Lightheadedness and dizziness
45. What are the two types of incentive spirometry?
Volumetric and flow-oriented
46. How does volumetric incentive spirometry work?
Volumetric incentive spirometry devices measure and visually indicate the volume achieved during a maneuver. They employ a bellow that rises according to the inhaled volume. When the patient reaches the target inspiratory volume, a controlled leak in the device allows the patient to sustain inspiratory effort for a short period of time.
47. How does flow-oriented incentive spirometry work?
Flow-oriented devices measure and visually indicate the degree of inspiratory flow. This flow can be equated with volume by assessing the duration of inspiration.
48. What do both types of incentive spirometers do?
They attempt to encourage the same goal for a patient, which is to achieve a sustained maximum inspiratory effort in order to prevent or correct atelectasis.
49. What patients benefit from IPPB?
Patients who are at high risk for atelectasis but are unable to participate in patient-directed techniques, such as incentive spirometry or deep breathing.
50. What are the goals of IPPB?
To help the patient take deeper breaths, promote a cough, improve the distribution of ventilation, and achieve improved ABG results.
51. What is the purpose of a cough?
To clear secretions from the airways
52. Which of the following is not a potential hazard of IPPB?
Increased cardiac output
53. Which of the following statements is not true about IPPB?
IPPB should be the single treatment modality for resorption atelectasis.
54. All of the following parameters should be evaluated after intermittent positive-pressure breathing therapy except:
Temperature
55. All of the following machine performance characteristics should be monitored during IPPB except:
Humidity output
56. Which of the following initial flow settings would you select when setting up a continuous positive airway pressure flow-mask system for a patient with atelectasis?
2 to 3 times the patient’s minute ventilation
57. In order to eliminate leaks in an alert patient receiving intermittent positive-pressure breathing therapy, which of the following adjuncts would you try first?
Nose clips
58. Which of the following patient groups should be considered for lung expansion therapy using IPPB?
Patients with clinically diagnosed atelectasis who are not responsive to other therapies and patients who are at a high risk for atelectasis who cannot cooperate with other methods.
59. Which of the following positions is ideal for intermittent positive-pressure breathing therapy?
Semi-fowler’s
60. What are the appropriate initial settings for intermittent positive-pressure breathing?
Sensitivity: -1 to -2 cmHO; Pressure 10 to 15 cmH2O; Flow: moderate
61. While administering IPPB, you notice that the device will not cycle off, even when you occlude the mouthpiece. What would be the most appropriate action to take?
Check the circuit for leaks
62. What is the minimum airway pressure at which the esophagus opens, allowing gas to pass directly into the stomach?
20 cmH2O
63. Which of the following will make an IPPB device cycle off prematurely?
Airflow obstruction, kinked tubing, occluded mouthpiece, and active resistance to inhalation
64. What is an absolute contraindication for using intermittent positive-pressure breathing?
Tension pneumothorax
65. During the administration of continuous positive airway pressure through a mask to a patient with atelectasis, you find it difficult to maintain the prescribed airway pressure. Which of the following is the most common explanation?
System or mask leaks
66. Which of the following is NOT a potential contraindication for intermittent positive-pressure breathing?
Neuromuscular disorders
67. Which of the following are potential desirable outcomes of IPPB?
Improved oxygenation, increased cough and secretion clearance, improved breath sounds, and reduced dyspnea
68. The general assessment for IPPB should include which of the following?
Measurement of vital signs, appearance and sensorium, and chest auscultation
69. What is the most common complication associated with IPPB?
Respiratory alkalosis
70. Which of the following should be charted in the patient’s medical record after completion of an intermittent positive-pressure breathing treatment?
Results of pre-and post-treatment assessment, any side effects, and succinct but complete account of the treatment session.
71. Which of the following are contraindications for continuous positive airway pressure (CPAP) therapy?
Hemodynamic instability, hypoventilation, and facial trauma
72. Which of the following are appropriate volume goals for IPPB?
10 to 15 mL/kg and at least 30% of the inspiratory capacity (IC)
73. Prior to starting IPPB on a new patient, what should the practitioner explain?
Why the physician ordered the treatment, what the treatment will do, how the treatment will feel, and what the expected results are.
74. Which of the following are potential complications of CPAP therapy?
Barotrauma, gastric distention, and hypercapnia
75. Which of the following is FALSE about gastric distention with IPPB?
Gastric distention is a relatively harmless effect of IPPB.
76. Which of the following mechanisms probably contribute to the beneficial effects of CPAP in treating atelectasis?
Recruitment of collapsed alveoli, decreased work of breathing, improved distribution of ventilation, and increased efficiency of secretion removal.
77. What is the optimal breathing pattern when using IPPB for the treatment of atelectasis?
Slow, deep breaths held at end-inspiration
78. Which of the following modes of lung expansion therapy is physiologically most normal?
Incentive spirometry
79. Which of the following are essential components of a CPAP system?
Blended source of pressurized gas, breathing circuit with reservoir bag, low-pressure or disconnect alarm, and expiratory threshold resistor.
80. Intermittent positive-pressure breathing is associated with what?
Passive exhalation
81. While administering intermittent positive-pressure breathing therapy, which of the following breathing patterns would be most desirable?
6 to 8 breaths/min with an I:E ratio of 1:3
82. The administration of IPPB should include which of the following?
The evaluation of alternative approaches to the patient’s problem, setting specific and individual clinical goals or objectives, and conducting a baseline assessment of the patient.
83. What do large negative pressure swings during inspiration indicate when IPPB is being administered?
Incorrect sensitivity
84. When adjusting the sensitivity control on an intermittent positive-pressure breathing device, which of the following parameters are you changing?
The effort required to cycle the device on
85. When you decrease the flow during IPPB, what happens to the inspiratory time?
It increases
86. What are the two types of atelectasis?
Passive and resorption
87. What is passive atelectasis?
It is the result of shallow breathing and is caused by the persistent use of small tidal volumes.
88. Passive atelectasis can occur with what?
Surgery medications, neurological disorders, neuromuscular weakness, bed rest, and immobility
89. Resorption atelectasis is the result of what?
It results from an airway obstruction (e.g., mucus plugs).
90. What is lobar atelectasis?
When an entire lobe of the lung has atelectasis
91. What factors cause atelectasis?
Obesity, neuromuscular disease, sedation, surgery, spinal injury, bedridden immobility, and a decreased cough.
92. What are the clinical signs of atelectasis?
Decreased breath sound with crackles, tachycardia, tachypnea, cyanosis, hypoxemia, and increased opacity on a chest x-ray.
93. Lung expansion therapy increases lung volumes by increasing what?
The transpulmonary pressure gradient
94. What happens if the transpulmonary pressure gradient is increased?
The lungs expand more
95. How does incentive spirometry work?
It increases the transpulmonary pressure gradient by lowering the pleural pressure. It is the most effective type of lung expansion therapy because it mimics the normal physiology of breathing.
96. How does IPPB work?
It increases the transpulmonary pressure gradient by increasing the alveolar pressure.
97. How do you know which lung expansion therapy method to choose?
It depends on the needed equipment, personnel, risk, and cost.
98. How does incentive spirometry mimic natural sighing?
By encouraging slow, deep breathing
99. Is IPPB used for short-term or long-term therapy?
Short-term
100. How frequently can IPPB be administered?
It can be administered several times a day or as frequently as once per hour.
101. What does IPPB require?
It requires a spontaneously breathing patient.
102. What are the four IPPB interfaces?
Mask, flange, trach adapter, and mouthpiece
103. What is the Bird Mark 7?
It is the most common type of IPPB that is pneumatically powered.
104. What are the IPPB controls?
Pressure, flow, sensitivity, air mix control, and apnea timer
105. Which of the following situations is a contraindication for incentive spirometry?
A patient with a vital capacity that is less than 10 ml/kg and a patient who cannot cooperate or follow instructions (e.g., unconscious patient).
106. Which of the following conditions is most likely to predispose a patient to atelectasis?
Surgery
107. When should high-risk surgical patients be oriented to incentive spirometry?
Before the surgical procedure
108. A patient complains of numbness around his lips during IS. What should the therapist recommend?
Tell the patient to slow their breathing rate
109. Physical signs of atelectasis that involve a significant portion of the lungs include:
Decreased or bronchial/tubular breath sounds, tachypnea, and tachycardia when hypoxemia is present.
110. In teaching a patient to perform the sustained maximal inspiration maneuver during incentive spirometry, what would you say?
“Exhale normally, then inhale as deeply as you can, then hold your breath for 5 to 10 seconds.”
111. A postoperative patient using incentive spirometry complains of dizziness and numbness. What is the most likely cause of these symptoms?
Hyperventilation
112. Which of the following is FALSE about flow-oriented incentive spirometry devices?
They have proved less effective than volumetric systems.
113. Which of the outcomes would indicate improvement in a patient previously diagnosed with atelectasis who has been receiving incentive spirometry?
Improved PaO2, decreased respiratory rate, and improved chest radiograph findings
114. Persistent breathing at small tidal volumes can result in which of the following?
Passive atelectasis
115. Correct instruction in the technique of incentive spirometry should include which of the following?
Diaphragmatic breathing at slow to moderate flows
116. Lung expansion therapy works because of an increase in what pressure gradient?
Transpulmonary
117. How often should a patient perform incentive spirometry?
Hourly
118. Lung expansion methods that increase the transpulmonary pressure gradients by increasing alveolar pressure include which of the following?
Positive end-expiratory pressure therapy, intermittent positive-pressure breathing (IPPB), and expiratory positive airway pressure (EPAP).
119. In observing a postoperative woman conduct incentive spirometry, you note the repetitive performance of the sustained maximal inspiration maneuver at a rate of about 10 to 12/min. Which of the following would you recommend?
Take a 30-second rest between breaths
120. Which of the following patient categories are at a high risk for developing atelectasis?
Those who are heavily sedated, those with upper abdominal or thoracic pain following surgery, and those with neuromuscular disorders.
121. Which of the following is not a potential hazard or complication of incentive spirometry?
Decreased cardiac output
122. How do all modes of lung expansion therapy aid in lung expansion?
By increasing the transpulmonary pressure gradient
123. When does acute respiratory alkalosis occur during incentive spirometry?
When the patient is breathing too quickly
124. An alert, cooperative 28-year-old female with no prior history of lung disease, underwent a cesarean section, and her x-ray film is clear. Which of the following approaches to preventing atelectasis would you recommend?
Incentive spirometry
125. The successful application of incentive spirometry depends on what?
The effectiveness of patient teaching
126. How can the transpulmonary pressure gradient be increased?
By increasing the alveolar pressure or decreasing the pleural pressure
127. Incentive spirometry devices can generally be categorized as which of the following?
Flow-oriented or volume-oriented
128. Which of the following is not at high risk for developing postoperative atelectasis?
Those with a non-smoking history
129. What is the pressure setting for IPPB?
10-20 cmH2O
130. What would you increase during IPPB to increase the patient’s tidal volume?
The pressure setting
131. If the patient can’t trigger an IPPB breath and the manometer needle is not moving off of the zero mark, what would you expect?
The patient is breathing through their nose
132. What is a device for lung expansion that requires negative transpulmonary pressure?
Incentive spirometer
133. What is an ideal I:E ratio when delivering IPPB?
An I:E ratio with a higher expiratory time
134. What is the purpose of EzPAP?
It helps with the prevention and treatment of atelectasis for lung expansion therapy, and it is recommended for patients with a decreased FRC.
135. What are some adverse reactions that occur with EzPAP?
Increased work of breathing that may lead to hypoventilation, increased intracranial pressure, cardiovascular compromise, decreased venous return, air swallowing, and pulmonary barotrauma.
Lung expansion therapy offers a multifaceted approach to managing and preventing respiratory dysfunction, particularly in at-risk populations.
By employing a combination of mechanical and manual techniques, healthcare providers can actively mitigate complications such as hypoxia and pneumonia.
As advancements in medical technology continue to evolve, optimizing the implementation of lung expansion therapy remains vital for maximizing its benefits, thereby playing a pivotal role in improving the quality of life for patients with compromised respiratory systems.
