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)

References;

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