Intermittent positive pressure breathing

Introduction

Intermittent positive pressure breathing (IPPB) is a technique used to provide short term or intermittent mechanical ventilation[1] via mouthpiece or mask for the purpose of augmenting lung expansion[2] and delivering aerosol medication[3]. IPPB is usually not a therapy of choice in treating lung collapse as there are other techniques that are less expensive, easy to administer and less tasking[4]; It usually implored when other therapies failed or patient is not cooporating. 

IPPB is inspiration using a non-invasive ventilator such as the Bird with a pressure boost. The patient stimulates inspiration, with positive pressure support, and followed by airway pressure returning to atmospheric pressure with passive expiration.The Bird Mark 7 ventilator is a pressure cycled device convenient to use for providing IPPB as an adjunct to physiotherapy in the spontaneously breathing patient[5]. IPPB may be applied to intubated as well as nonintubated patients[4][5]

Benefits of IPPB

IPPB has been shown to

  1. Increase the volume of  inspiration
  2. Support weak inspiratory muscles.In completely relaxed subject the work of breathing during inspiration is reduced immensely[6] with IPPB.
  3. Assist in clearing sputum from the lungs. The two prior benefits aids in bronchial secretions clearance when more simple airway clearance techniques alone are not maximally effective[7].
  4. Ease the inspiration of large volume of air
  5. Assist in the delivery of aerosol medication (nebulisers). The reduction in the work of breathing can be used with effect in the acute severe exhausted asthmatic, but there is no evidence that the effect of bronchodilators delivered by IPPB is greater than from a nebulizer alone[8].
  6. Improve the levels of oxygen and carbon dioxide in your blood

Indication for IPPB[4][5]

  1. The need to improve lung expansion in the presence of atelectasis when other forms of therapy(incentive spirometry, Chest Physiotherapy Technique, Deep Breathing Exercises, positive airway pressure adjuncts) have been unsuccessful.
  2. Inability of the patient to clear secretions adequately because of pathology that severely limits the ability to ventilate or cough effectively and failure to respond to other modes of treatment.
  3. Patient who have an acute flare-up of their breathing problem and are too weak to have an effective cough
  4. The need to deliver aerosol medication to the patient 

Procedures for IBBP using Bird mark Ventilator[5]

  • Explain procedure to patient.
  • Attach circuit corrugated tubing, expiratory valve line, and nebulizer tubing to IPPB machine. Pressure test the circuit and machine to insure proper function; open up nebulizer control, set inspiratory pressure level, and cycle the machine manually.
  • Block the mouthpiece with sterile gauze or the sterile circuit package. The machine should cycle off when the preset inspiratory pressure is reached.
  • Aseptically prepare medication as prescribed and insert in the IPPB nebulizer.
  • Instruct patient to:

a. Purse lips around mouthpiece so air do not leak, keeping the tongue back.

b. Breathe through the mouth only. Mask may be used if patient is unable to cooperate

with mouthpiece.

c. Inspire slowly and deeply not letting air “puff” cheeks out. Pause briefly at end of inspiration then exhale.

  • After patient is comfortable with this technique, treatment can begin.
  • Set sensitivity to cycle on with patient’s inspiratory effort.
  • Adjust inspiratory pressure to 10 – 15 cmH2O, assessing adequate volume by chest expansion and auscultation.
  • Adjust nebulizer controls to have medication nebulized adequately.
  • Monitor patient throughout duration of treatment.
  • When treatment is complete, detach circuit from IPPB machine, discard any excess solution from nebulizer, and place circuit in plastic bag at bedside for use with next treatment.
  • Age appropriate considerations include assessing the patient’s ability to cooperate with a mouthpiece. An appropriate fitting mask may be used if necessary in geriatrics.

Contraindications for IPPB[9]

  1. Increased intracranial pressure.
  2. Hiccups
  3. Hemodynamic instability.
  4. Recent facial, oral, or skull surgery.
  5. Tracheoesophageal fistula.
  6. Recent esophageal surgery.
  7. Active haemoptysis.
  8. Nausea.
  9. Active, untreated tuberculosis or other respiratory communicable disease..
  10. Radiographic evidence of bleb.

Resources

https://www.aarc.org/wp-content/uploads/2014/08/05.03.0540.pdf

https://www.atsjournals.org/doi/abs/10.1164/arrd.1974.110.6P2.13?journalCode=arrd

References

  1. Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane. http://www.cochrane.org/CD003212/NEONATAL_nasal-intermittent-positive-pressure-ventilation-nippv-versus-nasal-continuous-positive-airway (accessed 25 May 2018).
  2. Breathing and Temporary Positive Expiratory Pressure in Patients With Severe Chronic Obstructive Pulmonary Disease. Bronconeumologia. 2014; 50:1. DOI: 10.1016/j.arbr.2013.12.008 p1-50.
  3. Handelsman H. Intermittent positive pressure breathing (IPPB) therapy. Health Technol Assess Rep. 1991;1:1-9. PMID:1810351
  4. 4.0 4.1 4.2 Hough, A. Physiotherapy in Respiratory Care; An evidence-based approach to respiratory and cardiac management. 3rd eds. United Kingdom: Nelson Thomes Ltd, 2001 p.69
  5. 5.0 5.1 5.2 5.3 Pryor JA, Webber BA. Eds. Physiotherapy for Respiratory and Cardiac problems. 2ndedition. Churchill Livingstone, London. 1998; p158-159
  6. Bott J, Keilty SE, Brown A. Nasal intermittent positive pressure ventilation. Physiotherapy, 1992; 78, 93-96.
  7. Pavia D.  Bronchoalveolar clearance. Respiration, 1991; 5 8 (suppl.),  p.13-17.
  8. Dhand R. Aerosol Bronchodilator Therapy During Noninvasive Positive-Pressure Ventilation: A Peek Through the Looking Glass. Respiratory care. 2005; 50:12. P1621-1622.
  9. AARC Clinical Practice Guideline. Intermittent Positive Pressure Breathing. Respiratory Care, 2003; 8(5) pp.540-546.