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Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and

Job Title (author)

Intermittent Positive Pressure Breathing (IPPB) Guidelines for Practice Regan Bushell, Senior Physiotherapist

Directorate & Speciality Date of submission Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis)

Diagnostics and Clinical Support, Physiotherapy September, 2012 September, 2015 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


This guideline describes the use of IPPB in selfventilating and tracheostomy patients for the purposes of physiotherapy treatment for the purpose of improving lung expansion and assisting pulmonary secretion clearance

Key Words

IPPB BIRD Reduced lung volumes Sputum retention

Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasiexperimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer Consultation Process

Yes 3, 4 and 5

Senior Respiratory Physiotherapists

Target audience

Physiotherapists working in respiratory care

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.

Intermittent Positive Pressure Breathing (IPPB) Guideline for Practice 2012

Version: This replaces the IPPB Guideline for Practice, March 2009 Review Date: September 2015 Contact: Regan Bushell, Senior Physiotherapist, Ext: 66095 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 patients spontaneous effort.

Indications For Use IPPB has been shown to increase Tidal Volume (VT) and Minute Ventilation (MV), therefore the rate of alveolar ventilation. This can have the effect of improving Pa02 levels and reducing PaC02. 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 VT 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)

Contraindications Undrained Pneumothorax (or suspected by the presence of surgical emphysema) is an absolute contraindication to IPPB

Intermittent positive pressure breathing (IPPB) Guideline 2012

Precautions (Discuss with Specialist Registrar /Consultant prior to use) 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 Cardiovascular System Instability (hypotension and arrhythmias) Raised ICP 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 02 machine is to be used) Complications Air swallowing (particularly problematic if it occurs in anti-reflux surgery patients) Hypotension due to positive pressure reducing venous return Patient intolerance Pneumothorax and lung injury may occur in any patient with indiscriminate and uncontrolled use of IPPB

Intermittent positive pressure breathing (IPPB) Guideline 2012

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 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

Attach circuit to ventilator Connect IPPB ventilator to 02 gas supply. Maintain the patients current Fi02 where indicated until treatment is ready to commence. The O2 IPPB ventilator will provide approximately 40% 02 Switch ventilator on and demonstrate function to patient using the red manual override control on the left hand side of the ventilator

To establish ventilator patient connection To establish driving gas source and maintain adequate Fi02 Ensures correct functioning of the ventilator. Establish absence of leaks in the circuit Provides patient reassurance

Configure initial settings: Sensitivity or starting effort 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 cmH20 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

Inspiratory Flow Rate

Inspiratory Pressure

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

Intermittent positive pressure breathing (IPPB) Guideline 2012

Use the red manual override control if the patient needs help 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 patients 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

Ensure correct technique and maximise effectiveness of intervention Ensure patient safety including adequate Fi02 N.B. The BIRD will only supply 40% 02

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

Intermittent positive pressure breathing (IPPB) Guideline 2012

Good practice points Tidal volume must be increased to achieve a therapeutic effect Short periods of daytime IPPB should not be used to treat chronic respiratory failure in stable COPD Care must be taken to ensure settings achieve patient synchrony with the device to reduce the work of breathing Consider IPPB in acute exacerbations of COPD where the patients present with retained secretions but are too weak of tired to generate an effective cough. IPPB may be considered in acute exacerbations of COPD where patients do not have immediate access to non-invasive ventilation and intubation is not an option

Bott, 2009

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 is not a therapy of first choice in spontaneously breathing patients when other less expensive and less invasive therapies can reliably meet clinical objectives. IPPB should only be applied when clinically indicated 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 multi-disciplinary team.

Intermittent positive pressure breathing (IPPB) Guideline 2012

Equipment List 1. 2. 3. 4. Oxygen or air gas supply IPPB ventilator (air or oxygen) Ampoule of sterile normal saline (checked and prescribed) 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

Acknowledgement The authors would like to acknowledge Fiona Moffatt, Critical Care Outreach Physiotherapist at QMC for her help in producing these guidelines.

Intermittent positive pressure breathing (IPPB) Guideline 2012

IPPB Troubleshooting

Problem Machine does not function

Machine cycles of its own volition

Patient is unable to trigger the machine

Machine keeps delivering a breath and does not stop Machine seems to deliver a jerky breath / patient resists the inspiratory flow

Patient complaining of breathlessness/ difficulty breathing in or not getting enough air

Patient complaining of the machine blowing too hard Patient grimacing/ cheeks filling / active expiration (abdominals contracting) Poor thoracic expansion despite IPPB

Possible Solution Check it is switched on Check the gas supply is inserted correctly into the wall The starting effort may be too low and movement triggers a flow of gas Check that the controlled expiratory time switch is off Starting effort may be too high Inadequate seal at the interface If using a mouthpiece a nose clip may be required Inspiratory pressure may be set too high Loss of a seal at the interface may lead to the pre-set pressure not being reached 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 Starting effort may be too high leading to increased work of breathing Inspiratory flow rate may be too low, not matching the patients requirements Inspiratory pressure may be too low not matching the patients requirements Inspiratory pressure set too high Patient may be in pain Poor technique Unsuitable ventilator settings 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 ? VT sufficient for an effective cough ? Presence of secretions ? Adequate humidification/hydration ? Intact cough reflex

Patient still unable to clear secretions

Intermittent positive pressure breathing (IPPB) Guideline 2012


Disposable IPPB Circuit

Exhalation valve Wide bore and narrow bore tubing



IPPB Ventilator

On/Off switch Starting effort dial Inspiratory pressure dial Port for connecting IPPB circuit

Red manual over-ride control (not seen) Inspiratory pressure gauge Controlled expiratory time (switch to off)

Inspiratory flow rate dial

Intermittent positive pressure breathing (IPPB) Guideline 2012