· PDF fileOxygen therapy and humidification ... confusion, cyanosis . Oxygen Therapy ... O2 Hood ≥ 7 0.30 – 0.70

Noninvasive Positive Pressure Ventilation (NPPV)

AND

Oxygen Therapy

กภ. สุวรรณ ศรีดาทองกุล

The aims of rehabilitation

*to mobilize patients early **to facilitate weaning from mechanical ventilation ***to improve function by increasing strength and endurance

Outcome: Decreased Cost and Length of stay

Intervention Approach Active Passive

Non-invasive ventilation

IPPB BiPAP CPAP Cough assist

Management of breathlessness

Respiratory muscle training IMT Breathing techniques Breathing / coughing

Airway clearance techniques Postural drainage and manual techniques Cough assist

Suctioning

Airway clearance devices PEP therapies

PEP Acapella Flutter Breath Max

Oxygen therapy and humidification

Ultraneb Breath Max Humidified High Flow

IBBP with Heat

Before treatment : Precaution Prevention Action

GERD Check gastric content or 2hr.after meal

Hypoxia

Oxygenation

Sticky sputum , dry airway

NSS nebulizer or heat nebulizer*

Wheezing

Bronchodilator *

Restless ( intubated)

Sedative drug*

Wound pain Pain killer *

Nasal bleeding (edema)

Iliadin *

* Under doctor prescription

Condition Clinical features Physical therapy program

Chronic lung disease eg. Bronchiectasis

- Hypersecretion - PD , percussion,vibration - Acapella

- Cough assist machine - ± suction

The intubated pediatric

- Ineffective cough by tube - Hypersecretion - atelectasis

- Modified PD , percussion,vibration

- chest expansion - chest mobilization - suction

Post extubation

- Increase WOB - Hypersecretion

- Atelectasis

- EzPAP , IPPB Avoid deep

suction eg.subglottic edema - Gently PD with vibration

Post surgery

- Wound pain - Hypersecretion

- Atelectasis

- Mechanical or manual vibration - Cliniflow ,acapella

- Cough assist machine - Breathing exercise - ± suction

Condition Clinical features Physical therapy program

Neuromuscular disease

- Poor respiratory muscles strength and stamina + low FRC =

ineffective cough

- PD ,Percussion or vibration - Manually assisted cough or

mechanical cough assist - ± suction

Bronchiolitis - Productive cough with wheezing

- nasal congestion

- Clear upper airway - No percussion if wheezing

Asthma - Severe bronchospasm

- hypersecretion - atelectasis

- Avoid percussion and suction - PEP or PEP with oscillation to

prevent distal airway collapse - Breathing exercise : relaxation

Atelectasis - Non specific respiratory symptoms

- IPPB, EzPAP , Incentive spirometry ,breathing exc.

Passive Techniques Practical concern

Postural drainage - According to pathological lobes - Avoid prone and head down :Abdominal distention, GERD - Wound pain - Tube care

Percussion and vibration

- No percussion in age < 1 months : use vibration technique

- Avoid aggressive percussion especially < 8 months

- If PEEP > 5cmH2O NO percussion - Mechanical vibration 10-15Hz

Postural Drainage / Percussion / Vibration

Vibrator

Passive Techniques Practical concern

PSE: prolonged slow expiration (is a slow passive and progressive expiration from FRC to ERV)

- Useful for bronchiolitis patient - Head up 30 degree - No gastric content

Provoked cough (Briefly pressure on trachea at Suprasternal notch)

- Easily induce trauma

Cough ,huffing and Breathing exercise

- Poor cognitive ability - Passive or active or assistive devices

Passive Techniques

Practical concern

Suction

- Oxygenation to prevent hypoxia - No use lubricate gel in Neonate and Infant to

prevent airway obstruction - NSS : aspiration , infection - 5-10sec., 3-5 times to prevent arrthymia - Sterile technique to prevent infection - limit pressure to prevent atelectasis and bleeding - Type 1. nasal aspiration :upper airway

2. nasopharyngeal or oropharyngeal : upper airway or lower airway ( stimulated coughing)

3. nasotracheal :neuromuscular disease

4. suction in tube

Definition: Noninvasive Positive Pressure Ventilation (NPPV) is a ventilatory-assist technique used in the management of impending respiratory failure as an alternative to endotracheal intubation.

Acute respiratory failure

The primary objective of NIV is avoiding intubation and subsequently reducing mortality

Acute or chronic respiratory insufficiency

Secondary end points have faster improvement in gas exchanging and acid-base status, and reducing ICU and hospital stays

Intermittent Positive Pressure Breathing IPPB with Heat humidifier

Machine settings

• Sensitivity of 1 – 2 cm H2O

• Initial pressure between 10 – 20cm H20

• I:E ration of 1:3 to 1:4

• Flow and pressure will need subsequent adjustment

to patient’s needs and goal

Indications - Atelectasis not responsive to other therapies

[cough deep breath, and IS]

-Inability to clear airways due to inability to take

deep breaths

IPPB(Cont.)

Contraindications – Tension pneumothorax

– ICP > 15 mm Hg

– Hemodynamic instability

– Recent facial, oral or skull surgery, Tracheoesophageal fistula

– Recent esophageal surgery

– Active hemoptysis

– Nausea

– Air swallowing

– Active, untreated TB

– Radiographic evidence of bleb

Hazards and Complications Increased airway resistance

Pulmonary barotrauma

Nosocomial infection

Respiratory alkalosis

Impaired venous return

Gastric distension

Air trapping, auto-PEEP, overdistension

Psychological dependence

What does CoughAssist E70 do?

Non invasive alternative to deep suction

Can be given via facemask, mouthpiece,

endotracheal or tracheostomy tube

Simulates a cough

By applying a positive pressure (deep

insufflation) to the airway followed by a rapid shift

to a negative pressure to produce expiratory

flow from the lungs and effectively remove

secretions

Approved for adult and pediatric populations

Experiencing a natural cough

Mechanical cough assist : Providing inspiratory pressure then fast expiratory flow = stimulates cough

: Apply oscillation

: For a patient using this device for the first time, it is advisable to begin with lower pressures, such as 10 – 15 cmH2O positive and negative pressure, and low inhale flow. It will familiarize the patient with the feel of mechanical insufflation-exsufflation.

: As the patient becomes more comfortable with the therapy, progressively increase the inspiratory and expiratory pressures by 5 – 10 cmH2O each sequence of 4 – 6 breaths. Effective pressures may be around 35 – 45 cmH2O

Mechanical Insufflator-Exsufflator (Cough Assist)

Contraindication

• Bullous emphysema

• Pneumothorax or pneumo-mediastinum

• Recent Barotrauma

*Note*Patients with hemodynamic instability should

be carefully monitored

Physiological effects of HFNC

Pharyngeal dead space washout

Reduction of nasopharyngeal resistance

Positive expiratory pressure (PEEP effect)

Alveolar recruitment

Humidification great comfort and better tolerance

Better control of FiO 2 and bettets mucociliary clearance

Humidifier with integrated flow generator

Ultraneb

Acapella : PEP + oscillation

• Flutter ve Acapella

• Utilizes internal expiratory vibrations

• Oscillating endobronchial pressure clears mucus from small airways

Acapella

Flutter

PEP Therapy

Clear acapella with nebulizer

INDICATIONS

-Patients with chronic pulmonary conditions, such as Cystic Fibrosis and Chronic Bronchitis, which predispose them to large volume sputum production.

-To reduce air trapping in asthma and COPD.

-To optimize delivery of bronchodilators in patients receiving bronchial hygiene therapy.

EzPAP – 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

• 1. Patients unable to tolerate the increased work of

breathing (acute asthma, COPD)

• 2. Intracranial pressure (ICP) > 20 mm Hg

• 3. Hemodynamic instability

• 4.Recent facial, oral, or skull surgery or trauma

• 5. Acute sinusitis

• 6. Epistaxis

• 7. Esophageal surgery

• 8.Active hemoptysis

• 9. Nausea

• 10. Known or suspected tympanic membrane rupture

or other middle ear pathology

• 11. Untreated pneumothorax

BreatheMAX

• Humidifier • IS • Intrabronchial vibrator • PEP • IMT • EMT

CHEST PT

Incentive spirometer Sustained maximum inspiration

• There are 2 types

• Flow meter type

• Volume type

• Indications

1.To improve atelectasis

2.To prevent atelectasis

(post-op, COPD,

other pulmonary complications)

3.Mobilize secretions

Force or hold breathing

No

Inspiratory muscle training device

• Respiratory muscle endurance and strenght

• Cough efficiency Contraindication • Spontaneous pneumothorax • Traumatic pneumothorax after

complete recovery • Asthma patients who have low

symptom perception and who suffer from frequent sever exacerbations

• Recently experienced a perforated eardrum

Mechanism

Examples

Disorders of ventilation

Decreased ventilatory drive Decreased mental status (eg, caused by head injury, oversedation, sepsis, shock, or stroke)

Obstructed ventilation Bronchospasm Dislodgement of endotracheal tube Mucus plugging of the airways or endotracheal tube

Severe pain in the chest, abdomen, or both

Rib fractures Thoracic or abdominal surgery

Disorders of oxygenation

Pulmonary causes Acute respiratory distress syndrome Atelectasis, pneumonia, pneumothorax, pulmonary embolus, pulmonary contusion, aspiration pneumonitis

Nonpulmonary causes Iatrogenic fluid overload Heart failure (eg, due to exacerbation of underlying disease or to acute MI

Causes of Oxygen Desaturation

Oxygen Therapy

AIM

1.

2.

3.

Correct

Reduce

Reduce

Hypoxemia

work of breathing.

Myocardial work

PaO2 < 60 mmHg หรือ oxygen saturation < 90%

arterial hypoxemia tachypnea, tachycardia, agitation, confusion, cyanosis

Oxygen Therapy

INDICATIONS: •

•

Hypoxemia PaO2 ≤ 60 torr or Acute care situation: – Find the problem

– Find the appropriate treatment

Severe trauma

Acute myocardial infarction.

SaO2 ≤ 90 %

•

•

• Short-term therapy, surgical intervention,

post-anesthesia recovery or HBO

Oxygen therapy

To ensure safe and effective treatment remember:

Oxygen is a prescription drug.

Prescriptions should include

1.

2.

3.

4.

Flow rate.

Delivery system.

Duration.

Instructions for monitoring.

Consideration factors

Severity of hypoxia and symptoms. –

–

–

Oxygen consumption and equipment.

Moisture content

Oxygen Therapy

Oxygen Therapy

SETTING

The oxygen through

The oxygen through

normal airway.

artificial airway:

•

•

Endotracheal tube

Tracheostomy tube

Oxygen Therapy

Oxygen sources

–

–

–

Oxygen

Oxygen

Oxygen

Cylinder

Pipeline

Concentrator

Characteristics of oxygen delivery system

1. Low flow oxygen delivery system

“Variable performance” • Nasal cannula

• Simple mask

• Mask with reservoir bag

Low flow oxygen

Type Flow FiO2

Nasal cannula

1 0.24 2 0.28 3 0.32 4 0.36 5 0.40 6 0.44

Simple Mask

5 – 6 0.40 – 0.50 6 – 7 0.50 – 0.60 7 - 8 0.60

Partial rebreathing

Mask

6 0.60 7 0.70 8 0.80 9 ≥ 0.90 10 ≥ 0.90

Characteristics of oxygen delivery system

2. High flow oxygen delivery system

“Fixed performance” • Venturi mask

• Non-rebreathing mask

• Oxygen tent

• Incubator

• Mechanical ventilator

Oxygen Therapy

Baby : < 6

Type Flow rate FiO2 Humidifier

Nasal cannula Infant : < 2

0.24 – 0.40 Bubble humidifier

Simple Mask 5 - 10 0.35 – 0.50 Bubble humidifier

Partial rebreathing Mask 6 - 10 0.40 – 0.60 Bubble humidifier

Non rebreathing Mask ≥ 10 0.60 – 0.80 Bubble humidifier

O2 Hood ≥ 7 0.30 – 0.70 Jet humidifier

O2 Tent 10 - 15 0.40 – 0.50 Jet humidifier

Humidification

Humidifier Vs. Nebulizer

Humidifier

Nebulizer

Humidity

Gas

Aerosol

Characteristics of O2 delivery system

Low flow

High flow

FiO2

Variable

Fixed

Cost

Less

More

Infection

Less

More

MONITORING

Skin colors

Conscious

Breathing pattern

Respiratory rate

Chest and Abdominal movement

Accessory muscle breathing

Breath sound Lung sound

SaO2

Other symptoms.

Oxygen Therapy : Weaning

Tolerance of Weaning –

–

–

Consciousness

O2 > 90 %

HR change • ± 20, limit at

SBP change • ± 20, limit at

RR < 35 / min

Dyspnea

Lung sound

50 HR < 120

– 90 < SBP < 180

–

–

–

– Accessory muscle breathing

<

Physical Therapy in Oxygen Weaning

Prophylaxis O2 Therapy

Acute hypoxemia

Dyspnea

During Suction

Lung disease

Cardiac disease

Neuro disease

Post operative

Pre/Post Exercise

Ambulate

Night Support

Fit to fly

COMPLICATIONS

– Cut of hypoxemic ventilatory • Chronic hypoxic lung disease

• COPD

• Severe chronic asthma

• Bronchiectasis / Cystic fibrosis

• Chest wall disease

drive • Kyphoscoliosis

• Thoracoplasty

• Neuromuscular disease

• Obesity hypoventilation

–

–

–

–

–

Denitrogenation absorption

Oxygen toxicity

Drying of secretion

Fire hazard

Retinopathy of prematurity

atelectasis

RESPIRATORYCARE•FEBRUARY2009 VOL54 NO2

Peter C Gay MD. Complications of Noninvasive Ventilation in Acute Care. Respiratory. 2009; 54 NO2:246-258 .

PHILIP Respironic. Evaluation of Cough Assist (CA) Device with Adult Intensive Care Units (ICU)

J Bott, S Blumenthal, M Buxton S Ellum, C Falconer, R Garrod, A Harvey, T Hughes, M Lincoln, C Mikelsons, C Potter, J Pryor, L Rimington, F Sinfield, C Thompson, P Vaughn, J White, on behalf of the British Thoracic Society Physiotherapy Guideline Development Group . Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient :Joint BTS/ACPRC guideline.