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Wednesday, January 12, 2011

Down with IPPB

There is a reason those 40 year old green Bird Mark 7 IPPB machines are either in the dark side of the closet of the world's better hospitals or collecting dust in some foreign country's trash heap. Most studies show that the IPPB procedure is about as useless as the most renowned asthma expert of the 1800s ( Dr. Fredrick Hyde Salter) recommending syrup of ipecac to treat asthma.

The first Intermittent Positive Pressure Breathing (IPPB) Machines were marketed just after WWII.  Initially they were used as positive pressure ventilators, and proved to be a more effective means of ventilating polio victims because the patients were intubated.  This was better because you could get better tidal volumes and you could suction the airway.  Among the most reliable and durable of these machines was introduced in 1955 by Dr. Forrest Bird as the Bird Universal Medical Respirator, later called simply the Bird Mark 7 Universal Respirator, the Bird Mark 7, or simply the bird.  I prefer simply "The bird."

Yet once the poliomyelitis vaccination was given to kids throughout the 1950s and 1960s this put an end to the need for IPPB machines.  They also declined to be used for this purpose once volume ventilators with actual alarms were invented, especially with the advent of the Emerson Volume Ventilator (many describe it as a big, green washing machine) in 1964 and the MA1 in 1969.

In the 1950s many physicians believed IPPB treatments given three to four times per day for 10 to 15 minutes would be useful for the following:
  1. To overcome breathing resistance
  2. Provide more uniform alveolar aeration
  3. Distribute aerosols to terminal bronchioles where absorption takes place
  4. Relieve bronchospasm 
  5. Improve bronchial drainage, 
  6. Provide exercise for respiratory muscles
  7. Improve pulmonary function (1)
While such IPPB treatments were initially given for heart failure with foaming pulmonary edema, they were ultimately given for all lung diseases and all surgical patients, pre and post operative.  Treatable causes were believed to be:
  1. Pulmonary edema
  2. Atelectasis
  3. Bronchial asthma
  4. Bronchiectatsis
  5. Emphysema
  6. Pulmonary fibrosis
  7. Silicosis
  8. Impairment of respiratory function resulting from barbiturate poisoning and poliomyelitis (2)
Medications aerosolized in line with the IPPB treatment, and inhaled with each effective positive pressure breath were:
  1. Ethyl alcohol:  To calm the foaming bubbles in pulmonary edema
  2. Isuprel:  a bronchodilator used to relax smooth muscles in asthma, COPD
  3. Mucomyst:  A mucus thinner used to help COPD, CF patients expectorate sputum
  4. Alevaire:  A mucus thinner also used to help patients with thick sputum expectorate it.  (3)
Back then respiratory therapy departments were profitable, and every procedure performed made the RT department more profitable.  For this reason hospital administrators and RT bosses did not do anything to stop the abuse of IPPB machines.  Of course, neither did the makers of such machines, the most popular of which was the infamous Bird Mark 7.

By the 1970s the necessity of these devices came "under scrutiny" by insurance companies who had to flip the bill.  They claimed there was no proof the treatments did any good, and they were too expensive.  Such scrutiny was validated by researchers who proved by scientific evidence the following:
  1. IPPB therapy deposit 32% less of aerosolized medicine to the lungs than a simple aerosol treatment.  
  2. Any benefits provided from the therapy were also proven to be short lived, lasting less than an hour.  
  3. Inventive spirometers were equally as effective in preventing and treating postoperative atelectasis  (4)
The RT textbook, "Foundations of Respiratory Care," sums up IPPB therapy for us:  "The Overuse of IPPB was eventually to become an embarrassment to the profession, but in the 1950s and 1960s, IPPB devices could be seen throughout most hospitals in the United States."  Yet in many hospitals, including the ones I've worked for, continued to abuse this therapy throughout the 1980s and 1990.  By 2012 IPPB orders are rare, but still occur.  (5)
So use of the machines diminished throughout the remainder of the 1970s and became almost extinct by the 1980, except for in some small town hospitals where medical wisdom is slowly learned.  Where I work doctors continued to order these for post operative patients in the 1990s, and sometimes they do to this day.  In fact, I had to do one the other day.

Any breathing equipment that can be seen being used as a ventilator on re-runs of the show Emergency, which originally aired from 1972 to 1979, is a piece of equipment I don't want used on any relative, friend or patient of mine.  Our sagacious and senior RT here at the RT cave will write on this blog that she believes IPPB is of benefit under certain circumstances. She will write that when a patient is post op, not taking deep breaths, in pending respiratory failure and vent bait, the IPPB -- done correctly -- may prevent that patient from eminent failure. The key here is it must be done correctly, "Which I doubt most of you younger RTs do," she said.

She makes a good point. However I countered her argument with this: "How do you know it was the IPPB that made the patient better, and not the fact you were working with the patient to take deep breaths? Once again, it's easier to give credit to the machine than the technique."

I argue that working with a patient on taking good deep breaths with a breath hold, followed by cough (otherwise known as C&DB or cough and deep breathing), is the best method of treating these patients. I think C&DB is even better than doing an incentive spirometer (IS).

I have seen it work. I have seen elderly or disabled patients struggle with the IS, and I have rarely found a patient who can't perform C&DB exercises. I have seen (and studies have shown) that about 50% of patients cannot tolerate the IPPB, and don't do it the recommended 10 minutes. And as Jane notes, most RTs don't properly instruct the technique.

Some old timer physicians just don't seem to want to let go of the old IPPB theories -- and that's all they are is theories. They were taught of the benefits of this machine way back in the 1980s. They were taught based on wisdom from way back in the 1960s and even the 1950s, wisdom that was based on a made up myth. Once again, they like to give credit to the machine and not the technique. It is wisdom that is old and outdated -- like that ipecac for asthma therapy.

You can look at nearly every study done on this issue (
including this one) and not one of them proves that IPPB has any benefit over a regular Ventolin breathing treatment. In fact, most studies show Ventolin -- unless used to treat bronchospasm -- won't prevent a ventilator either (unless you give Preventolatorolin).

So there is a good reason those old reliable machines are collecting dust at the world's most renowned teaching hospitals. Slowly but surely as new doctors replace the old junk, I've seen the IPPB ordered less and less. The big question is: will the IPPB disappear by the simple process of assimilation before the old reliables finally bust apart?

Now, my co-worker (now retired co-worker) Jane Sage has promised to write a contrary post to this called Up with IPPB. Although she seems to think retirement is more important than writing for my blog, her post is a little slow coming. Hopefully she'll finish with her end of this argument. If not, then I WIN!!!!

(up with IPPB coming soon by Jane Sage)

  1. Hess, Dean R., et al, "Respiratory Care:  Principles and Practice," 2012, "Intermittent Positive Pressure Breathing," chapter 18, page 370  
  2. Stephen, Phyllis Jean, "Nebulization Under Intermittent Positive Pressure," The American Journal of Nursing," 1957, Sept., vol. 57, No. 9, pages 1158-1160 
  3. Stephen, ibid
  4. Hess, op cit
  5. Wyka, Kenneth A., Paul J. Mathews, William F. Clark, ed., "Fundamentals of Respiratory Care," 2002, . page 630, Section IV, Essential Therapeutics 


Anonymous said...

Is this anything like putting ALL vent patients on nebulized treatments or giving treatments to ALL Post-op CABG patients??

P.S. The aforementioned patients would be ones without ANY previous lung disease nor past smoking is just done to all, just cuz...........

Tonic563 said...

Hehe. My last clinical site had the Bird Mark 7's all pushed up into a little corner, which had me thinking..."birds of a feather flock together".

Rick Frea said...

lol. love it

Anonymous said...

I have to disagree as I have seen IPPB used VERY effectively in patients with lung collapse and secretion retention post thoracic sugery so maybe you need to think about selecting your patients more appropriately!

Rick Frea said...

There are some RTs whove said the same to me, however I don't think it's the IPPB so much as the fact someone is in the room working with the patient and encouraging them to take deep breaths. Studies show the IS is just as effective as IPPB in preventing and treating atelectasis.

Anonymous said...

Use of IPPB is definitely
beneficial for patients with severe
restrictive disease such as scoliosis, and patients suffering from neurological and neuromuscular deseases such as ALS,MS,and MD.
I work in a rehab hospital, and
the use of IPPB is instrumental in
the treatment of theses types of patients.

Anonymous said...

renamed the Dodo?

LaraB said...

Here is what I want to know if hospitals don't use this as lung expansion therapy anymore, why in the world must I know how this machine works (my CRT is next week) I read it over and over and get it....But no one uses them anymore at least here in NYC they don't

Rick Frea said...

The same reason I had to learn about the MAI when I took the test in 1997 -- because the test is always 10-20 years behind the real world.

Katrina G. said...

I think you have forgotten about patients with neuromuscular diseases. I find that with lung weakness, the IPPB greatly assists in getting deep breaths with the medicine, particularly when congested.

Rick Frea said...

BiPAP works better and is much safer.

Jesse said...

I am a patient with MD which was causes me to also have restrictive lung disease. I can tell you from experience that the IPPD machine does help. I used to have one for many years until the old machine broke and I wasn't able to find another. A nebulizer hasn't worked as well and Ive been sleep tested for a bi-pap. It did not resolve my breathing issue.

john bottrell said...

I find that interesting. IPPB basically applies pressure support to your air passages, and so does BIPAP. The difference is BiPAP is safer because it gives you, the patient, control over how much air you are inhaling.

Anonymous said...

I stumbled upon this blog post as I was searching for you tube videos on using a Bird IPPB machine. I recently started working at the UNIVERSITY OF MICHIGAN hospital and was shocked to find out that I'd be using Bird IPPB machines multiple times every shift I work! They use them every day all day long!

john bottrell said...

At the University of Michigan? Wow! How could such a state of the art hospital use such antedeluvian equipment? Since we got hospitalists at our hospital our little green monsters have become coat racks in our storage room.

By the way, if you watch "Mad Max" you can see this old peace of junk used as a ventilator. It's later in the movie when his wife is on a ventilator. The movie was made in 1979 and the machine was outdated even then.

Anonymous said...

I also agree that people with neuro- muscular disease benefit from IPPB. I'm a retired RT, and I have some respiratory issues, and I do better with IPPB. I have both a nebulizer, and an old Portabird at my house. I use the nebulizer for the most part, but when things get rough, that bird keeps me out of the ER. I feel IPPB has a place in respiratory care, even though a small place, I think all hospitals should have a Bird or a Bennett machine in good working order, and RTs should be trained in the proper use of the machines.......Provided the instructors know how. By the way, I've only been retired a year, after 43 years in the field, and I've seen things come back too, as if they are a new invention.....such as the coughilator......we had cough machines back in the 70's, now they're back. Pulmozyne, reformulated pancreatic dornase, or much like the old dornovac for the cystics and many more things I've seen come and go and come back, so don't discount it.

migraineur said...

I don't think the Birds have no use what so ever...I've personally used them with post op open chest pts...ones that are capable of taking deep breaths, but not willing. I drag it in, set it up, and they take about five breaths, whining after every breath. About then, they ask why I'm making them do this, and I tell them that because they wouldn't take a deep enough breath on their IS. I'm required to use the IPPB until they can hit _____(insert goal volume here). I get much better effort on their IS, not because they weren't able, but because it hurts less to take an ~1000mL IS breath over almost any IPPB breath.

We also have one trauma doc that orders it Q4ever, and exempts the pt from our protocol. Mostly on any lung fracture pts who came in with anything illegal or illicit in their systems...both because they usually have respiratory depression (from both pain and the illegal drugs) and as a bit of revenge from the doc for being stupid and driving impaired, then ending up in his trauma OR.

I fought the doctor who wanted it on a pt with a history of tracheal stenosis ...she'd had bowel surgery, and you could see a HUGE gas bubble at the descending colon...which she was struggling to pass-it was the size of both my fists, and this was a tiny ~115lb lady. She complained that the pain made her short of breath. The intern and I were in agreement that Gas-X would be a more effective therapy, but his attending overruled both of us.

林子軒 said...

I believe that IPPB is a good breath exercise for some certain disease.