Wednesday, April 18, 2012

Up with IPPB

As my regular readers know, I am not a fan of the IPPB as I wrote in my post "Down with IPPB."  Yet if you are ordered to use it you might as well do it right. 

For this reason I approached one of my fellow RTs -- Jane Sage --who's been working in the field since the mid-1980s.  She provides us with the following IPPB wisdom:

Many of our newer respiratory therapists don't know this, but that little green IPPB (Intermittent Positive Pressure Breathing) machine that sits in the corner of storage rooms collecting dust used to be ordered for admitted patients like Ventolin is ordered today.  

Those little machines first hit the market in the 1950s and were your first positive pressure ventilators.  I bet you didn't know that.  The problem with using this pneumatic device as a ventilator is that you were forcing a set pressure into a patient and there were no alarms.  Likewise, you had no idea actual pressure you were using, and you had no idea what volumes you were pushing into the patient.

If you ever watch old episodes of that old movie called "Emergency" from back in the 1970s you can see the IPPB used as a ventilator.  I don't know if you've ever heard of that old show, but I used to enjoy watching it, even if it was somewhat medically inaccurate.  For instance, every time CPR was given the patient would instantly wake up and be fine and walk off.  I've never seen that in real life, yet I digress.

So as better ventilators were invented, such as the Emerson and MA1 volume ventilators,  the IPPB was released from it's duty as a ventilator. Yet much like the makers of baking powder tried to find other ways of re-marketing their product, so did the makers of the IPPB machine. Doctors were convinced that IPPB therapy would benefit every patient admitted with a respiratory disease.  This was already going on in the 1950s, and it continued to the 1970s.   

It was believed that the positive pressure breaths from this machine would re-open resistant alveoli and benefit post operative patients, and therefore prevent and treat atelectasis.  It was also believed it would force bronchodilators deeper into the lungs, and enhance the effect of this therapy.  So IPPBs were used for just about every patient.  

When we had paralyzed patients ordered to take this therapy, or stroke patients, we used to use a special mouthpiece and we'd hold it over their mouths for the entire treatment. 

In fact, it became such a common device that in some places there were clinics where several IPPB machines were bolted to tables and COPD patients lined up for their daily IPPB treatment.  The patient would sit down and get his treatment.  When he was finished the circuit was replaced with a new one and the next patient sat down.

Yet then studies were done to show that the IPPB could actually do more harm than good to some patients with lung disease.  For example, if an emphysema patient had blebs, too high of a pressure could pop a bleb and cause an even greater problem, and even death. It was also learned that IS therapy was equally as effective as IPPB, that the pressures required to prevent atelectasis were rarely reached, and IPPB therapy actually made bronchodilators work less well, not more.  So IPPBs slowly declined, so that they are rarely ever ordered today.  

By the 1990s the IPPB machine was used for post operative patients to treat atelectasis.  Yet by the late 1990s newer RTs weren't taught about this machine in RT school as most hospitals phased them out altogether.  RT teachers didn't want to spend quality time teaching about a device that was seldom used. 

So by the 2000s the device was still ordered on occasion, yet when it was ordered the therapy wasn't provided adequately by poorly trained clinicians.  Yet I contest to this day that in certain conditions IPPB therapy can be very beneficial, and it's not above me to recommend it from time to time on the right patient.

Usually these patients will be post operative patients who aren't taking adequate breaths and are an impending respiratory distress waiting to happen.  Using the IPPB for these patients can help to open those resistant alveoli and prevent the patient from buying a ventilator.

If you are ordered to use it you should know how to use it correctly.  If you don't use it correctly it's nothing more than a glorified incentive spirometer.  So, how do you use it correctly?  How do you know if the patient is using it correctly?

First, you dial in the settings.  A good place to start is a Peak Inspiratory Pressure (PIP) of 10 and a flow of 10.  The sensitivity is usually set at about five.  Then you adjust the settings to meet the demands of the patient.  Ideally, PIP should never exceed 15.  Rarely did I ever have to go higher.

You fill the cup on the circuit with whatever medicine is ordered, usually it's Ventolin or Xopenex.  During the 1980s we usually used Alupent, yet that medicine has been since phased out because it has a greater cardiac effect than today's watered down bronchodilators.  Back in teh 1950s ethyl alcohol was used for heart failure, Isuprel was a bronchodilator used for asthma and COPD, and mucomyst was used as a mucus thinner in COPD and CF patients.  Yet now it's usually Ventolin or Xopenex.  

Then you tell the patient to place the mouthpiece between his lips, close his mouth around it, and to start to inhale.  Yet you will want to tell the patient to allow the machine to fill his lungs with air.  When the set pressure is met, the expiratory cycle will be triggered and the patient can exhale. 

To know the patient is using the device correctly you watch the pressure gauge.  When the patient triggers the breath the pressure gauge should go negative for a second (like to -5 cwp) and then it should go positive.  The pressure should gradually be increased until the expiratory cycle has begun.

Now, if the pressure goes way negative, such as to negative 10 or 20, then you know the patient is sucking in too hard.  When this occurs the patient is using the device as a glorified incentive spirometer and you are wasting your time.  You will want to coach the patient so he is using the device correctly.

A good IPPB therapy takes time and lots of coaching.  It's okay to give the patient a break every few minutes, yet the therapy should be continued until the medicine in the medicine cup is gone. A full duration IPPB treatment should be about 10 to 15 minutes.  And I must add, since you are using pressures that could be dangerous if improperly used, the therapist must stay in the room with the patient during the entire treatment.  It's not like a neb treatment where you can leave the room if necessary.  If you leave the room, if you must leave the room, please stop the treatment.  I knew of an RT once who was fired because he left IPPB patients unattended.  Not good.  

So there you have it.  IPPB therapy may not be as in demand as it once was, yet from time to time it can be a very effective therapy for the right patient.  When used correctly, IPPB therapy can prevent further deterioration of a patient's medical condition. 

Thanks, Jane Sage

Thank you, Jane.  We always appreciate your wisdom.  We hope you're enjoying your retirement.

Also read:  The IPPB Revolution:  The history of Intermittent Positive Pressure Breathing

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