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Wednesday, July 23, 2008

This RT thinks IPPB therapy is useless

So, I'm watching this old show called Emergency for no better reason than the fact I loved this show when I was a kid. I remember watching it in, say, 1976 or so on Saturdays. In fact, every Saturday I looked forward to this show.

Anyway, it's 30 years later and I find a re-run of this show at 3:00 in the morning while I'm working one night here at Shoreline, and just as I'm about ready to get up and go check on my patients, the scene switches to a patient in critical care on a ventilator.

The room looked nothing like the rooms of today, and the acting was of questionable quality, but I can tell you that my eyes lit up when I saw the ventilator: a bird mark 7 respirator.

Heck, we have these sitting at the back side of our respiratory storage room collecting dust, and most hospitals have probably thrown theirs out or given them to some foreign nation as a charitable donation.

What a sight it was not just to see this old IPPB machine, but to see it used as a ventilator.

Believe it or not, I have seen this machine used as a ventilator short term during a catscan of an intubated patient, but that was before we had super fast catscan technology, and before the advent of the transport ventilator.

And to believe that on occasion we still use this piece of junk, the same piece of junk that was used to ventilate patients 30 years ago, is scary medicine.

Last weekend I could have choked one of my co-workers because she asked a doctor to write an order for this machine. I wanted to choke her because it was a doctor who never would have thought of ordering this on his own.

However, I diplomatically smiled at my favorite co-worker and said, "Cool."

Why was I disgruntled at this IPPB request, when my co-worker was only trying to do what she thought was best for the patient? Because I'd hate for this doctor to learn to like the IPPB and want to order it again.

Yes, the patient did get better that day, but it was his fourth day post-op, and during the night before I had decreased his oxygen from a NRB to a 50% VM. He was making great progress with cough and deep breathing excercises and Preventolin breathing treatments alternated with cracklin nebs to re-inflate the collapsed alveoli (see olins bottom of blog for more detail here).

Needless to say, the IPPB (Bird mark 7) was a good machine in its day, but now its used to force air into a patient and force them to take a deep breath -- if it is used or taught properly, and it rarely is.

The theory is that it is good for post-op patients, in that it works as a glorified incentive spirometer to expand collapsed (atelectic) alveoli, and exercise the good alveoli. It's about a 5-10 minute therapy session.

However, most studies show that all the IPPB really does is over-expand the good alveoli, and does nothing for the collapsed alveoli. In other words, it's an over-hyped piece of junk.

(Click here for a video of how the IPPB works that might soon be seen only in RT museums.)

Now, some of the RTs who have worked here a lot longer than me, however, truly believe this IPPB can do some good for some patients. They say that it has kept some patients off the ventilator.

However, I think what really kept those patients off the ventilator was the special attention they received from the RT, the incentive spirometry enforcements, the encouraging of the patient to cough and deep breathe with good breath hold. All of that coupled with moving the patient as often as possible.

I don't think it was the IPPB that made my patient better. I hate that thing. I think it's an ineffective waste of my time and the patient's time. I think the only thing it's good for is good old TV, like I saw the other day when I watched that old re-run of Emergency.

I loved that show.

Further reading:


Intubate Em!!! said...

There is a lovely dr who likes to order DuoNeb with 3cc of mucomyst via ippb followed by cpt q4 & prn.

The patients are usually so exhausted they end up refusing some or all of their tx.

Freadom said...

I bet you get a lot of requests for that prn IPPB.

kwcawley said...

RT's that believe IPPB is useless, don't have enough experience. It's only useful in a very small number of pts but can really help buy some time when a pt can't tolerate continuous BIPAP.

Freadom said...

This is one of the few areas where my coworker Jane Sage and I disagree. She thinks the IPPB can help people avoid a vent in rare instances. I think continual encouragement to c&db works just as well if not better than IPPB.

However, in medicine, you do whatever YOU THINK will help the patient most. If you've had past good outcomes with IPPB, then go for it.

Anonymous said...

I think that in 99% of cases, IPPB is totally 100% useless. It just makes the patient hate their treatment. However, we use it here on a lot of trached patients who lack muscle strength and cognitive awareness.

Apart from that though? I think we should pitch them all in the dumpster.

Freadom said...

Which brings us to another discussion. I actually had a trach patient the other day who was recently extubated. The thought crossed my mind of asking for IPPB. The I decided she did pretty well with C&DB, so I pitched the idea. Still, a trach patient may be a good use for IPPB. What are your thought?

Anonymous said...

As an asthma patient, I have had a few of these IPPB treatments via a similar machine. The last time I had to go in twice, and was actually worse the second day than the first. So, maybe there is some credence to your statement. The steroid shot is what ultimately helped me. What is an asthma patient to do when she takes nebulizer treatments which seem to work, yet sometimes they are not enough? Steroid shots are hard on your body, but they are effective. I know this is an old blog, but I pose the question now, as I have had a rough January!

Rick Frea said...

I think you're thinking of a breathing treatment, not IPPB. Usually it's just an inpatient procedure and is extremely rarely used anymore. A breathing treatment is simple, safe and -- yes -- used when it's not needed.

Rick Frea said...

Correction. Often used when it's not needed. Although if you have asthma, a breathing treatment can come in handy.

Anonymous said...

When I started doing RT,IPPB was king,so I have quite a bit experience using the Bennett and Bird machines.I agree that using the machines to its full potential requires consistent interaction with the patient.
I found that by using low pressures in the 10-15 cmP range and active inspiratory effort patients were able to tolerate the Tx better.
Another interesting tidbit was that our department actually put together a PEEP circle for use with IPPB Tx.