Intermittent Positive Pressure Breathing (IPPB) Guideline Full Title of Guideline: Intermittent Positive Pressure Breathing (IPPB) Guidelines for Practice Author (include email and role): Regan Bushell, Senior Physiotherapist, regan.bushell@nuh.nhs.uk Division & Speciality: Version: 3 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Clinical Support, Physiotherapy Senior Physiotherapists at NUH Trust wide physiotherapists September, 2021 Self-ventilating and tracheostomy patients with reduced lung volumes and/or retention of pulmonary secretions. Exclusion criteria includes an undrained pneumothorax and the guideline describes a number of precautions that require discussion with the medical team prior to the commencement of IPPB. Review of research, minor changes to wording, grammar and spelling errors corrected. Change of contraindication to precaution (removal of chest drain). Well designed non-experimental descriptive studies (ie comparative / correlation and case studies). Expert committee Summary of evidence base this reports or opinions and / or clinical experiences of respected guideline has been created from: authorities. Recommended best practise based on the clinical experience of the guideline developer This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Page 1 of 9
Intermittent Positive Pressure Breathing (IPPB) Guideline for Practice 2018 Version: This replaces the IPPB Guideline for Practice, September 2015 Review Date: September 2021 Contact: Regan Bushell, Senior Physiotherapist, 07812269729 or Eleanor Douglas Lecturer/Practitioner Physiotherapist. Ext: 56142 Disclaimer This guideline has been registered with the Nottingham University Hospitals Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in any doubt regarding this procedure, contact a senior colleague. Caution is advised when using guidelines after the review date. Please contact the named above with any comments/feedback. Introduction This guideline describes the procedure for the use of Intermittent Positive Pressure Breathing (IPPB) for the purposes of physiotherapy treatment in adult patients. IPPB is a technique used to provide short- term or intermittent mechanical ventilation for the purpose of augmenting lung expansion or assisting ventilation. IPPB uses a pressure-limited ventilator that applies a positive inspiratory pressure, which is triggered by the patient s spontaneous effort. Indications For Use IPPB has been shown to increase Tidal Volume (V T ) and Minute Ventilation (MV), therefore the rate of alveolar ventilation. This can have the effect of improving Pa0 2 levels and reducing PaC0 2. The application of the positive pressure reduces the work of breathing associated with inspiration. IPPB may be of value in the following situations: 1. To augment V T in the presence of hypoventilation due to weakness, fatigue or diminished level of consciousness. 2. Assisting secretion clearance where pathology or fatigue limits the ability to cough or ventilate effectively N.B. Used in isolation, IPPB will have no effect on functional residual capacity (FRC) Page 2 of 9
Precautions (Discuss with Specialist Registrar /Consultant prior to use) Un drained pneumothorax Air swallowing (particularly problematic if it occurs in anti-reflux surgery patients) Hypotension due to positive pressure reducing venous return Patient intolerance Maxfax surgery where an oral flap is used Facial fractures Unprotected brain aneurysm (Mr G Dow patients only at QMC campus) Recent oesophageal, pulmonary or anti-reflux surgery Gastric distention with no ng in situ Cardiovascular System Instability (hypotension and arrhythmias) Raised ICP Uncontrolled pain Nausea Bronchospasm Pulmonary oedema Extreme tachypnoea Large airway carcinoma Emphysematous bullae and/or evidence if intrinsic PEEP Unexplained heamoptysis Self -ventilating patients with a known hypoxic drive (if 0 2 machine is to be used) Pneumothorax and lung injury may occur in any patient with indiscriminate and uncontrolled use of IPPB Page 3 of 9
Guideline for Practice Action Gain consent from the patient and explain the effects of IPPB Prepare the patient by ensuring analgesia and information is given as required Position the patient according to assessment findings and treatment aims Select interface: full facemask or mouthpiece (a nose clip may be required) or via tracheostomy Assemble IPPB circuit, filling the nebuliser chamber with 5mls of sterile, normal saline. Check the saline amount and expiry date with another qualified member of staff e.g. nurse or physiotherapist Attach circuit to ventilator Connect IPPB ventilator to 0 2 gas supply. Maintain the patients current Fi0 2 where indicated until treatment is ready to commence. The O 2 IPPB ventilator will only provide approximately 40% 0 2 Switch ventilator on and demonstrate function to patient using the red manual override control on the left hand side of the ventilator Rationale Confirms the patient is willing to undertake the treatment Minimises patient discomfort, thereby maximising the effectiveness of the procedure Maximise effectiveness of procedure by optimising gas distribution To ensure appropriate patient ventilator connection and minimise air leaks Drug is given as prescribed and avoids administration errors Provides humidification to the inhaled gas To establish ventilator patient connection To establish driving gas source and maintain adequate Fi0 2 Ensures correct functioning of the ventilator. Establish absence of leaks in the circuit Provides patient reassurance Configure initial settings: Sensitivity or starting effort Inspiratory Flow Rate Inspiratory Pressure Set low to allow patient to breath in easily without increasing work of breathing Commence at mid range. Increase if patient is very breathless, then reduce as able to optimise gas distribution Commence at approximately 10 cmh 2 0 Increasing as necessary according to patient response Prevents the machine cycling automatically All other controls should be switched off Ensures the correct technique and maximises the effectiveness of the treatment Apply interface and commence treatment. Instruct the patient to initiate a breath and then allow the machine to fill their lungs with air, then to breathe out passively Use the red manual override control if the patient needs help Page 4 of 9 Ensure correct technique and maximise
initially to coordinate with the ventilator Monitor the patient throughout the treatment: For any signs of distress Synchrony with ventilator Thoracic expansion Cheek filling Air swallowing Abdominal distension Pulse oximetry Cardio-vascular instability Adjust the settings as required to match patient demand, progress and treatment Continue treatment for as long as required. Reduce inspiratory pressure intermittently if using over a prolonged period Add manual techniques as required If a cough is stimulated, discontinue IPPB temporarily Once the treatment has finished restore pre-treatment respiratory support Monitor the patients observations to ensure level of support is still adequate Rinse out the nebuliser chamber with sterile water and dry thoroughly Use a patient hospital label to identify the patients IPPB circuit and store in a plastic bag by the patient s bedside IPPB circuits should be changed on a weekly basis the date of commencement of the use of the circuit should be clearly marked on the hospital label Report any adverse effects or changes in patients overall condition to nursing and/or medical personnel Document procedure, effects and response as per documentation policies effectiveness of intervention Ensure patient safety including adequate Fi0 2 N.B. The BIRD will only supply 40% 0 2 Maximise effectiveness of intervention Prevent hyperventilation and hypocarbia Maximise effectiveness of treatment promotes removal of secretions Allows the patient to expectorate Re-establish respiratory support Maintains patient safety Prevents the potential for bacterial contamination Prevents cross contamination For infection control purposes Patient safety Legal requirement Best Practice Training IPPB will not be performed by physiotherapy or nursing staff who have not been trained and been deemed competent Education will be a mandatory inclusion in the in-service training programme for the Band 5 physiotherapy staff respiratory rotation Education will be offered in the emergency duty induction programme Opportunities will be offered to senior staff wishing to maintain their skills in IPPB Treatment IPPB should only be applied when clinically indicated and then proven to have been effective. All of the mechanical effects of IPPB are short lived, lasting less than an hour after treatment. The therapist must therefore aim to maximise treatment carry over by educating the patient, the carers and the multidisciplinary team. Page 5 of 9
Equipment List 1. Oxygen or air gas supply 2. IPPB ventilator (air or oxygen) 3. Ampoule of sterile normal saline (checked and prescribed) 4. IPPB circuit to include: a. Appropriate patient interface (facemask, mouth piece or catheter mount for tracheostomy patients) b. Connector tubing (wide bore tube and narrow bore tube) c. Complete nebuliser unit d. Exhalation valve References AARC Clinical Practice Guideline IPPB (2003) Respiratory Care 48,5: 540-546 Bott J et al (2009) Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax 64: (Suppl 1)ii-i151 Bott J and Keilty S and Noone L (1992) IPPB A dying art? Physiotherapy 78, 9: 656-660 Denehy L and Berney S (2001) The use of positive pressure devices by physiotherapists.eur Respir J 17: 821-829 Page 6 of 9
IPPB Troubleshooting Problem Possible Solution Machine does not function Check it is switched on Check the gas supply is inserted correctly into the wall Machine cycles of its own volition The starting effort may be too low and movement triggers a flow of gas Check that the controlled expiratory time switch is off Patient is unable to trigger the machine Starting effort may be too high Inadequate seal at the interface If using a mouthpiece a nose clip may be required Machine keeps delivering a breath and Inspiratory pressure may be set too high does not stop Loss of a seal at the interface may lead to the pre-set pressure not being reached Machine seems to deliver a jerky breath / patient resists the inspiratory flow Starting effort may be too low, therefore the patient is unable to synchronise with the sudden breath Inspiratory flow rate is too high, therefore the patient is unable to synchronise with a rapid breath Poor patient technique Patient complaining of breathlessness/ difficulty breathing in or not getting enough Starting effort may be too high leading to increased work of breathing air Inspiratory flow rate may be too low, not matching the patients requirements Inspiratory pressure may be too low not matching the patients requirements Patient complaining of the machine blowing Inspiratory pressure set too high too hard Patient grimacing/ cheeks filling / active Patient may be in pain expiration (abdominals contracting) Poor technique Unsuitable ventilator settings Poor thoracic expansion despite IPPB Inspiratory pressure may be set too low (may need increasing if patient has reduced lung compliance) Inappropriate/ inadequate patient positioning Inspiratory flow needs reducing to improve gas distribution and prolong inspiratory time Patient still unable to clear secretions? VT sufficient for an effective cough? Presence of secretions? Adequate humidification/hydration? Intact cough reflex Page 7 of 9
APPENDIX 1 Disposable IPPB Circuit Exhalation valve Wide bore and narrow bore tubing Mouthpiece Nebuliser IPPB Ventilator On/Off switch Starting effort dial Inspiratory pressure dial Red manual over-ride control (not seen) Port for connecting IPPB circuit Inspiratory pressure gauge Controlled expiratory time (switch to off) Inspiratory flow rate dial Page 8 of 9
Intermittent positive pressure breathing (IPPB) Guideline 2018 9