NIV proven useful for COPD, CHF, yet failure rates still high

Noninvasive ventilation (NIV), either in the form of Noninvasive Positive Pressure Ventilation (NPPV) or Continuous Positive Airway Pressure (CPAP), has been used in the critical care setting since the end of the 1980s, and is now commonly used in both Europe and the United States for the treatment of COPD exacerbatons and heart failure.

Studies also show that NIV may significantly decrease work of breathing, either by improving minute ventilation (COPD) or by decreasing venous return to the heart (CHF), and thereby reducing the need for intubation to 15% (although it is as high as 38% in patients with chronic respiratory disease).

However, despite it being so commonly used, and despite all the advancements in technology and equipment that have improved patient comfort, studies continue to show that anywhere from 20-30% of patients fail.  Of the patients who fail, 30-40% require intubation and mechanical ventilation.

A good indication of failure, or a good predictor of who will fail, is hypercapnia after initiation of NIV.

Contou et al, however, concluded that experienced respiratory therapists may make adjustments at the patient interface (mask) or changes in settings that make the experience more comfortable and more effective, thus resulting in a reduction in NIV failure rates to under 15%, thereby reducing mortality rates to 5%.

Contou et al also showed that, by using an NIV protocol and having the patient closely monitored in by experienced personnel, including a nurse and respiratory therapist, 48% of patients who were semi-comatose responded well to NIV therapy without the need for intubation.

The study shows that trialing patients on NIV in an experienced unit where the patient was closely monitored, even those who would otherwise have been intubated, has proven to be effective, thus further reducing the need for intubation.

Likewise, the researchers reported, "it has been shown that NIV failure was not associated with an increased mortality rate in hypercapnic patients; thus, delayed intubation in some patients likely did not worsen their outcome."

The bottom line here is that NIV protocols that allow the nurse and respiratory therapist to closely monitor and adjust the settings on the NIV "might reduce the intubation rate.

References:

1. Contou, Damien, Chiara Fragnoli, Ana cordoba-Izquierdo, Florence Boissier, Christan Brun-Buisson, and Arnaud W. Thille, "Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure:  Intubation Rate in an Experienced Unit," Respiratory Care, December, 2013, volume 58, number 12, pages 2045-2052

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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BiPAP is the new IPPB

So I had an IPPB ordered the other day, and this was the first time in a long time. It was the same doctor who still believes in the hypoxic drive hoax. He pretty much believes everything the media chants.

So, BiPAP is the new IPPB. While IBBB is seldom ordered now (it basically just overinflates the good alveoli according to most studies), BiPAP seems to have taken its place. Now obviously there are many wonderful uses for BiPAP, and it's prevented many patients from being placed on a vent, yet it is often abused just like any other medical therapy.

Just the other day I was called STAT to ER to set up a BiPAP. I said, "The patient is breathing fine."

"Yes," the doctor said, "but I want to get her blood pressure up."

"What?"

"I want to get her blood pressure up."

"What?"

"I... just set up the BiPAP." She rolled her eyes and left the room.

I said, "Well, all it's gonna do is make him agitated."

"Good," the doctor said as she trudged off, "I want her to become agitated. I want her blood pressure up."

"I might as well intubate her and do an ABG with the largest needle I can find if that's all you want to do," I mumbled under my hot breath. "What a waste of my time and the governments (our) money. What a waste!!"

And you wonder why there is so much apathy on the part of RTs.

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 

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:

• Up with IPPB (coming soon to RT cave)
• Down with IPPB

IPPB still in use at hospitals; still ineffective

Upon coming back to work today I find we have a patient on IPPB. I haven't done an IPPB on a patient in at least four years, and I'm surprised those darn things still work. After all, they were used in the 1960s as a ventilator at this hospital.

In fact, if you watch that old show from the early 1970s called "Emergency," on one of the episodes you will see the IPPB being used as a ventilator. I used to love that show when I was a kid.

One of these days those things are simply going to break down and I don't know what our doctors are going to do when they think one will help a patient stay in the hospital longer. After all, all studies done since the late 1980s show that all IPPB is good for is over-inflating the good alveoli.

"The patient is complete white out on the left side," Dave said.

"So, who ordered IPPB?" I asked.

"Oh, Dr. Arse."

"Why? Isn't it contraindicated for pneumo?"

"Well, it's not a pneumo," chuckles, "it's crackles. But don't worry, it should only do minimal damage to the patient. As soon as you're done with the treatment his good alveoli should deflate to normal size and he should be fine. It should only prolong his stay here one to two days."

"Okay," I said, "at least there's a good reason behind it. I'd hate to be doing an ancient procedure for nothing."

"Yep."

"What's doctor Arse going to do when our IPPBs finally break down due to wear and tear, and the company no longer exists to send in replacement parts?"

"Well, those machines are made to last a lifetime, kind of like Duracel batteries; they keep going and going and going. Then again, if they do happen to break down, I guess Dr. Arse will just have to retire."

"I think we should have hiden those things in the basement with the mist tents and told the doctors that we don't have them anymore, then they'd be forced to use some more effective therapy."

Dave chuckled, "Well, then they'd just give continuous inflatolin treatments."

Okay, so that's how my night started. It must have been a rough week for him.

On a side note here, the IPPB machine we have is so old and outdated that I can't even find a picture of it to post for you here.