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Title of Guideline (must include the word “Guideline” (not protocol, policy, procedure etc) Intermittent Positive

Title of Guideline (must include the word “Guideline” (not protocol, policy, procedure etc)

Intermittent Positive Pressure Breathing (IPPB) Guidelines for Practice

Contact Name and Job Title (author)

Regan Bushell, Senior Physiotherapist

Directorate & Speciality

Diagnostics and Clinical Support, Physiotherapy

Date of submission

September, 2012

Date on which guideline must be reviewed (this should be one to three years)

September, 2015

Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis)

Self-ventilating and tracheostomy patients with reduced lung volumes and/or retention of pulmonary secretions

Exclusion criteria includes an undrained pneumothorax and the guideline describes a number of precautions that require discussion with the medical team prior to the commencement of IPPB

Abstract

This guideline describes the use of IPPB in self- ventilating and tracheostomy patients for the purposes of physiotherapy treatment for the purpose of improving lung expansion and assisting pulmonary secretion clearance

Key Words

IPPB BIRD Reduced lung volumes Sputum retention

Statement of the evidence base of the guideline – has the guideline been peer reviewed by colleagues?

Yes

3, 4 and 5

Evidence base: (1-5)

1a

meta analysis of randomised controlled trials

1b

at least one randomised controlled trial

2a

at least one well-designed controlled study without randomisation

2b

at least one other type of well-designed quasi- experimental study

3

well –designed non-experimental descriptive studies (ie comparative / correlation and case studies)

4

expert committee reports or opinions and / or clinical experiences of respected authorities

5

recommended best practise based on the clinical experience of the guideline developer

Consultation Process

Senior Respiratory Physiotherapists

Target audience

Physiotherapists working in respiratory care

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after

Intermittent Positive Pressure Breathing (IPPB) Guideline for Practice 2012

Version: This replaces the IPPB Guideline for Practice, March 2009 Review Date: September 2015 Contact: Regan Bushell, Senior Physiotherapist, Ext: 66095 or Eleanor Douglas Lecturer/Practitioner Physiotherapist. Ext: 56142

Disclaimer This guideline has been registered with the Nottingham University Hospitals Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in any doubt regarding this procedure, contact a senior colleague. Caution is advised when using guidelines after the review date. Please contact the named above with any comments/feedback.

Introduction

This guideline describes the procedure for the use of Intermittent Positive Pressure Breathing (IPPB) for the purposes of physiotherapy treatment in adult patients. IPPB is a technique used to provide short- term or intermittent mechanical ventilation for the purpose of augmenting lung expansion or assisting ventilation. IPPB uses a pressure-limited ventilator that applies a positive inspiratory pressure, which is triggered by the patient’s spontaneous effort.

Indications For Use

IPPB has been shown to increase Tidal Volume (V T ) and Minute Ventilation (MV), therefore the rate of alveolar ventilation. This can have the effect of improving Pa0 2 levels and reducing PaC0 2 . The application of the positive pressure reduces the work of breathing associated with inspiration. IPPB may be of value in the following situations:

1. To augment V T in the presence of hypoventilation due to weakness, fatigue or diminished level of consciousness.

2. Assisting secretion clearance where pathology or fatigue limits the ability to cough or ventilate effectively

N.B. Used in isolation, IPPB will have no effect on functional residual capacity (FRC)

Contraindications

Undrained Pneumothorax (or suspected by the presence of surgical emphysema) is an absolute contraindication to IPPB

Intermittent positive pressure breathing (IPPB) Guideline 2012

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Precautions (Discuss with Specialist Registrar /Consultant prior to use)

Maxfax surgery where an oral flap is used Facial fractures Unprotected brain aneurysm (Mr G Dow patients only at QMC campus) Recent oesophageal, pulmonary or anti-reflux surgery Gastric distention Cardiovascular System Instability (hypotension and arrhythmias) Raised ICP Pain Nausea Bronchospasm Pulmonary oedema Extreme tachypnoea Large airway carcinoma Emphysematous bullae and/or evidence if intrinsic PEEP Unexplained heamoptysis Self -ventilating patients with a known hypoxic drive (if 0 2 machine is to be used)

Complications

Air swallowing (particularly problematic if it occurs in anti-reflux surgery patients) Hypotension due to positive pressure reducing venous return Patient intolerance Pneumothorax and lung injury may occur in any patient with indiscriminate and uncontrolled use of IPPB

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Guideline for Practice

Action

Rationale

Gain consent from the patient and explain the effects of IPPB

Confirms the patient is willing to undertake the treatment

Prepare the patient by ensuring analgesia and information is given as required

Minimises patient discomfort, thereby maximising the effectiveness of the procedure

Position the patient according to assessment findings and treatment aims

Maximise effectiveness of procedure by optimising gas distribution

Select interface: full facemask or mouthpiece (a nose clip may be required) or via tracheostomy

To ensure appropriate patient– ventilator connection and minimise air leaks

Assemble IPPB circuit, filling the nebuliser chamber with 5mls of sterile, normal saline. Check the saline amount and expiry date with another qualified member of staff e.g. nurse or physiotherapist

Drug is given as prescribed and avoids administration errors Provides humidification to the inhaled gas

Attach circuit to ventilator

To establish ventilator patient connection

Connect IPPB ventilator to 0 2 gas supply. Maintain the patients current Fi0 2 where indicated until treatment is ready to commence. The O 2 IPPB ventilator will provide approximately 40% 0 2

To establish driving gas source and maintain adequate Fi0 2

Switch ventilator on and demonstrate function to patient using the red manual override control on the left hand side of the ventilator

Ensures correct functioning of the ventilator. Establish absence of leaks in the circuit Provides patient reassurance

Configure initial settings:

 

Sensitivity or starting effort

Set low to allow patient to breath in easily without increasing work of breathing

Inspiratory Flow Rate

Commence at mid range. Increase if patient is very breathless, then reduce as able to optimise gas distribution

Inspiratory Pressure

Commence at approximately 10 cmH 2 0 Increasing as necessary according to patient response

Prevents the machine cycling automatically

All other controls should be switched off

Apply interface and commence treatment. Instruct the patient to initiate a breath and then allow the machine to fill their lungs with air, then to breathe out passively

Ensures the correct technique and maximises the effectiveness of the treatment

Intermittent positive pressure breathing (IPPB) Guideline 2012

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Use the red manual override control if the patient needs help initially to coordinate with the ventilator

Ensure correct technique and maximise effectiveness of intervention

Monitor the patient throughout the treatment:

 

For any signs of distress Synchrony with ventilator Thoracic expansion ‘Cheek filling’ Air swallowing Abdominal distension Pulse oximetry Cardio-vascular instability

Ensure patient safety including adequate Fi0 2

N.B. The BIRD will only supply 40% 0 2

Adjust the settings as required to match patient demand, progress and treatment

Maximise effectiveness of intervention

Continue treatment for as long as required. Reduce inspiratory pressure intermittently if using over a prolonged period

Prevent hyperventilation and hypocarbia

Add manual techniques as required

Maximise effectiveness of treatment promotes removal of secretions

If a cough is stimulated, discontinue IPPB temporarily

Allows the patient to expectorate

Once the treatment has finished restore pre-treatment respiratory support

Re-establish respiratory support

Monitor the patients observations to ensure level of support is still adequate

Maintains patient safety

Rinse out the nebuliser chamber with sterile water and dry thoroughly

Prevents the potential for bacterial contamination

Use a patient hospital label to identify the patients IPPB circuit and store in a plastic bag by the patient’s bedside

Prevents cross contamination

IPPB circuits should be changed on a weekly basis the date of commencement of the use of the circuit should be clearly marked on the hospital label

For infection control purposes

Report any adverse effects or changes in patients overall condition to nursing and/or medical personnel

Patient safety

Document procedure, effects and response as per documentation policies

Legal requirement

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Good practice points

Tidal volume must be increased to achieve a therapeutic effect

Short periods of daytime IPPB should not be used to treat chronic respiratory failure in stable COPD

Care must be taken to ensure settings achieve patient synchrony with the device to reduce the work of breathing

Consider IPPB in acute exacerbations of COPD where the patients present with retained secretions but are too weak of tired to generate an effective cough.

IPPB may be considered in acute exacerbations of COPD where patients do not have immediate access to non-invasive ventilation and intubation is not an option

Bott, 2009

Best Practice

Training

IPPB will not be performed by physiotherapy or nursing staff who have not been trained and been deemed competent

Education will be a mandatory inclusion in the in-service training programme for the Band 5 physiotherapy staff respiratory rotation

Education will be offered in the emergency duty induction programme

Opportunities will be offered to senior staff wishing to maintain their skills in IPPB

Treatment

IPPB is not a therapy of first choice in spontaneously breathing patients when other less expensive and less invasive therapies can reliably meet clinical objectives. IPPB should only be applied when clinically indicated

All of the mechanical effects of IPPB are short lived, lasting less than an hour after treatment. The therapist must therefore aim to maximise treatment ‘carry over’ by educating the patient, the carers and the multi-disciplinary team.

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Equipment List

1. Oxygen or air gas supply

2. IPPB ventilator (air or oxygen)

3. Ampoule of sterile normal saline (checked and prescribed)

4. IPPB circuit to include:

a. Appropriate patient interface (facemask, mouth piece or catheter mount for

tracheostomy patients)

b. Connector tubing (wide bore tube and narrow bore tube)

c. Complete nebuliser unit

d. Exhalation valve

References

AARC Clinical Practice Guideline IPPB (2003) Respiratory Care 48,5: 540-546

Bott J et al (2009) Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax 64: (Suppl 1)ii-i151

Bott J and Keilty S and Noone L (1992) IPPB – A dying art? Physiotherapy 78, 9: 656-660

Denehy L and Berney S (2001) The use of positive pressure devices by physiotherapists.Eur Respir J 17: 821-829

Acknowledgement

The authors would like to acknowledge Fiona Moffatt, Critical Care Outreach Physiotherapist at QMC for her help in producing these guidelines.

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IPPB Troubleshooting

Problem

Possible Solution

Machine does not function

Check it is switched on

Check the gas supply is inserted correctly into the wall

Machine cycles of its own volition

The starting effort may be too low and movement triggers a flow of gas

Check that the controlled expiratory time switch is off

Patient is unable to trigger the machine

Starting effort may be too high

Inadequate seal at the interface

If using a mouthpiece a nose clip may be required

Machine keeps delivering a breath and does not stop

Inspiratory pressure may be set too high

Loss of a seal at the interface may lead to the pre-set pressure not being reached

Machine seems to deliver a ‘jerky’ breath / patient resists the inspiratory flow

Starting effort may be too low, therefore the patient is unable to synchronise with the sudden breath

Inspiratory flow rate is too high, therefore the patient is unable to synchronise with a rapid breath

Poor patient technique

Patient complaining of breathlessness/ difficulty breathing in or not getting enough air

Starting effort may be too high leading to increased work of breathing

Inspiratory flow rate may be too low, not matching the patients requirements

 

Inspiratory pressure may be too low not matching the patients requirements

Patient complaining of the machine blowing too hard

Inspiratory pressure set too high

Patient grimacing/ cheeks filling / active expiration (abdominals contracting)

Patient may be in pain

Poor technique

 

Unsuitable ventilator settings

Poor thoracic expansion despite IPPB

Inspiratory pressure may be set too low (may need increasing if patient has reduced lung compliance)

Inappropriate/ inadequate patient positioning

Inspiratory flow needs reducing to improve gas distribution and prolong inspiratory time

Patient still unable to clear secretions

? VT sufficient for an effective cough

? Presence of secretions

? Adequate humidification/hydration

? Intact cough reflex

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APPENDIX 1

Disposable IPPB Circuit

Exhalation valve Mouthpiece Nebuliser
Exhalation
valve
Mouthpiece
Nebuliser

Wide bore and narrow bore tubing

Mouthpiece Nebuliser Wide bore and narrow bore tubing IPPB Ventilator On/Off switch Starting effort dial

IPPB Ventilator

Nebuliser Wide bore and narrow bore tubing IPPB Ventilator On/Off switch Starting effort dial Inspiratory pressure
On/Off switch
On/Off
switch
Starting effort dial
Starting
effort dial
Inspiratory pressure dial
Inspiratory
pressure
dial
switch Starting effort dial Inspiratory pressure dial Inspiratory flow rate dial Red manual over-ride
Inspiratory flow rate dial
Inspiratory
flow rate
dial

Red

manual

over-ride

control

(not

seen)

Port for

connecting

IPPB circuit

Inspiratory pressure gauge

Controlled expiratory time (switch to off)

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