7 Hyperinflation Therapy

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and the WRE, it will be shown simply as: (Code: …). If an item is testable only on the ELE, it will be shown as: (ELE code: …). If an item is testable only on the WRE, it will be shown as: (WRE code: …).

Following each item’s code will be the difficulty level of the questions on that item on the ELE and WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall [R] level questions typically expect the exam taker to recall factual information. Application [Ap] level questions are harder because the exam taker may have to apply factual information to a clinical situation. Analysis [An] level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision.

Note 2: A review of the most recent Entry Level Examinations (ELE) has shown that an average of two questions (1% of the exam) will cover hyperinflation therapy. A review of the most recent Written Registry Examinations (WRE) has shown that an average of two questions (out of 100), or 2% of the exam, will cover hyperinflation therapy.

MODULE A

Perform coughing and deep-breathing procedures with the patient to help make breathing more effective.

1. Instruct the patient in deep-breathing techniques (Code: IIID1a) [Difficulty: ELE: R, Ap; WRE: An]

Explain to the patient that taking in deep breaths keeps the small air sacs in the lungs inflated and healthy. Deep breathing and coughing are indicated in patients with atelectasis, pulmonary infiltrates, or pneumonia. These exercises should help to increase secretions. It is especially important to use deep breathing and coughing to prevent or limit atelectasis and pneumonia in patients who have just had abdominal surgery such as cholecystectomy or splenectomy. Ideally, the patient is taught these techniques before surgery is performed. If not, teach them the following postoperatively:

1. To decrease the pain, minimize traction or tension on the incision by placing your or the patient’s hands on both sides of the incision. Alternatively, the practitioner or the patient can hold a pillow against the incision.

2. Instruct the patient to breathe two or three times in through the nose and out through the mouth.

3. Instruct the patient to take in as deep a breath as possible and to perform a normal cough.

4. If the patient cannot cough normally because of pain, a serial cough can be performed.

Teach the following cough techniques to the patient with obstructive airways disease:

1. Avoid an ineffective, shallow, hacking cough.

2. Position the patient in a sitting position, bent slightly forward, with feet on the floor or supported. The patient who must lie in bed can be positioned on the preferred side with the legs flexed at the knees and hips.

3. Instruct the patient to perform a mid-inspiratory cough.

a. Breathe two or three times in through the nose and out through the mouth.

b. Breathe in to a comfortable volume larger than the tidal volume (V_T), but not as deeply as possible.

c. Briefly hold the breath.

d. Cough hard, or perform a serial cough at relatively low flows. This should help to raise secretions without causing airway collapse.

e. Squeezing the knees and thighs together at the instant of coughing helps to increase the airflow and volume.

Coaching is important because patients in pain or who are suffering from chronic lung disease tend to be uncooperative and to not try hard. Give positive reinforcement when the patient does well. Correct any problems that the patient is having in trying to follow the instructions. Demonstrations often are helpful, so the patient can copy a good example.

2. Instruct the patient in inspiratory muscle training techniques (ELE code: IIID1b) [Difficulty: R, Ap]

Initially, teach the following steps to patients with obstructive airways diseases:

1. Have the patient lie in a comfortable supine position; knees can be flexed.

2. Instruct the patient to relax physically as much as possible, especially the shoulders.

3. Use soothing music, meditation, or other techniques for mental relaxation.

4. Instruct the patient to concentrate on breathing more slowly.

5. Emphasize pursed-lip breathing, wherein the patient with relaxed abdominal muscles breathes in slowly through the nose and out slowly through pursed (slightly opened) lips. Breathing with pursed lips keeps some backpressure on the airways so they stay open longer. The technique helps to improve gas exchange so the patient experiences less dyspnea.

After these first steps have been mastered, teach the following steps to patients with obstructive airways diseases:

1. The practitioner places his or her hands and the patient’s hands gently over the area(s) where the patient is to concentrate the breathing effort. Usually, this is the abdominal area just below the sternum. This encourages the patient to use the diaphragm more effectively and to strengthen it. With diaphragmatic breathing, the hands move out during an inspiration.

2. The same hands-on technique can be used to aid in segmental breathing over an area that is underventilated or that has atelectasis.

3. Breathing in against an obstruction can also increase the strength and endurance of inspiratory muscles. A variety of devices are available. One type of device is a mouthpiece with selectable, variably sized openings at the other end (Figure 7-1). The patient breathes in through the largest opening and progresses to smaller openings as tolerated.

Figure 7-1 PFLEX inspiratory muscle trainer. The body of the device features a dial selector with inspiratory holes. The holes range from the 1 setting (largest opening) to the 6 setting (smallest opening). A one-way valve allows the patient to expire. The mouthpiece can be attached directly to the body, or a monitoring/oxygen adapter can be added between them. This adapter allows oxygen to be added to meet the patient’s needs. An inspiratory force meter also can be added to determine the amount of negative pressure the patient is generating at each of the inspiratory hole settings.

(Courtesy of Philips Respironics, Murrysville, PA.)

Increasing the strength and endurance of inspiratory muscles usually requires a training program similar to the following:

1. Plug the nose with nose clips.

2. Inspire a normal tidal volume (V_T) at a rate of 12 to 15 breaths/min through the largest opening.

3. Continue for 10 to 15 minutes per day for a total of 3 to 5 times/wk in the first week. If the patient notices shortness of breath, a noticeably increased pulse rate, or increased fatigue, the exercise should be stopped until the symptoms are gone. Resume the exercise when the patient is comfortable again.

4. Gradually increase the duration to about 30 minutes per session or two 15-minute sessions per day.

5. When this schedule can be tolerated easily 3 times/wk, switch to the next smallest hole.

6. Repeat steps 1 to 5 as tolerated. The most beneficial exercise is tiring but not exhausting. The device may be adjusted to the next larger hole setting if the patient becomes too tired. The whole process usually takes 4 to 6 weeks before positive results are seen.

7. A maintenance program necessitates that exercise be done every other day.

MODULE B

Incentive spirometry

1. Instruct the patient in incentive spirometry techniques (Code: IIID1a) [Difficulty: ELE: R, Ap; WRE: An]

Incentive spirometry (IS) is a technique whereby a patient is encouraged to breathe deeply by seeing his or her inhaled volume on the spirometry device. The patient receives positive feedback by seeing that the volume gradually increases as his or her condition improves. IS is indicated in any patient who has developed or is likely to develop atelectasis and can perform the procedure. Clinical situations and individuals in which atelectasis is likely to be seen include postoperative thoracic or upper abdominal surgery, the aged, the obese, inadequate sigh, cardiopulmonary disease, and quadriplegia and/or dysfunctional hemidiaphragm(s).

Exam Hint 7-1 (ELE, WRE)

Remember that incentive spirometry is the preferred treatment choice for atelectasis in patients who can perform it properly.

Because the goal of IS is to prevent or treat atelectasis, the patient should inhale a near-normal inspiratory capacity (IC). The patient can benefit more by holding the IC for several seconds, which is referred to as sustained maximal inspiration (SMI). Before the operation, the cooperative surgical patient should have the IC measured at the bedside or calculated from a pulmonary function test in which vital capacity (VC) is measured (review Chapter 4 for IC information). The IC is measured again postoperatively.

Before you start to provide instruction, make sure that the patient is alert and cooperative enough to follow instructions. The patient’s respiratory rate should be less than 25 breaths/min if the procedure is to be performed properly. Use the following steps in teaching IS:

1. Have the patient sit in semi-Fowler’s position, on the edge of the bed, or up in a chair.

2. Set an initial goal of twice the patient’s measured bedside V_T.

3. Tell the patient the purpose of the treatment and how to perform it properly.

4. Simulate the procedure for the patient.

5. Put the unit within easy reach, and keep it upright.

6. Have the patient exhale normally (to functional residual capacity), seal the lips around the mouthpiece, and inspire maximally through the unit. The patient must inspire in a slow, controlled effort.

7. Have the patient hold the IC for at least 3 seconds but no longer than 15 seconds before exhaling (the SMI).

8. Proceed to extend the patient’s goal as tolerated and indicated earlier.

9. The patient should perform the deep breath at least 10 times/hr while awake. With normal breathing, a rest period should take place after each large breath.

Monitor your patient’s progress in the following ways:

1. If the patient cannot meet the initial goal, reconsider whether this is the best form of treatment. Intermittent positive-pressure breathing (IPPB) might be a better choice for providing a deep breath.

2. Stop the treatment temporarily if the patient has signs of hyperventilation, such as dizziness or tingling of the fingertips. A few minutes of normal breathing should result in a normal feeling again. Have the patient take longer rest periods between maximal breaths.

3. Stop the treatment if the patient complains of acute chest pain. It is possible to cause pulmonary barotrauma by breathing in as deeply as possible. Evaluate the patient’s pulmonary condition and call the physician if indicated.

2. Increase or decrease the patient’s incentive spirometry goal (Code: IIIF2b) [Difficulty: ELE: R, Ap; WRE: An]

See Table 7-1 for IS guidelines. The following guidelines are also suggested:

1. Set the initial IC goal at twice the V_T.

2. Increase the goal in 200-mL increments as the patient tolerates.

3. Set a final IC goal of greater than 12 mL/kg of ideal body weight, or set a forced vital capacity (FVC) goal of greater than 15 mL/kg of ideal body weight.

4. A normal person should have an IC of about 75% of his or her FVC. For example, a predicted FVC of 5.166 L was calculated for a male patient in Chapter 4

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2. Suctioning the Airway
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4. Pulmonary Function Testing

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